Wiki physicals and "sick" visits together


Fallbrook, CA
Best answers
When a patient comes in for a physical I believe their "ongoing" problems eg: diabetes,hypertension,hyperlipidema, are all covered under the "physical", however if the patient has a cold, they can charge an E/M code also, it this true? and also what if they have a new problem such as hyperlipidema can they charge a E/M code. Thank you
When a patient presents for a well visit, their ongoing problems are considered part of that service unless one or more of those problems needs addressed because it is uncontrolled - eg: patient comes in for well visit, their hypertension is uncontrolled and the provider changes their medication. Their notes must document this and to determine the level of service, you must extract this from the physical documentation. It's really best documented by a separate note.

If the patient comes in for a well visit and has a cold, a separate E/M code can be billed if the provider documents this. Again, you need to pull out that piece of the exam to determine the level of service. A separate note is best!

A new problem, such as hyperlipidemia, can also be billed separately. Remember documentation is key to billing these things in addition to the well visit. There must be a clear statement that these conditions were examined and treated by the provider separate from the physical.

Also, don't forget to append modifier 25!