Prevent and problem oriented visit

Bobby A

Networker
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Dittmer , MO
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Provider see's a patient for a prevent, during exam based on age provider diagnosis strep throat (patient has not S/S). There is no CC/HPI, ROS, PFSH related to sore throat. Provider now has an assessment and RX to manage the strep throat.

Can we bill both prevent and problem visit?

Thank you
 

jdibble

True Blue
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Daytona Beach, FL
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Provider see's a patient for a prevent, during exam based on age provider diagnosis strep throat (patient has not S/S). There is no CC/HPI, ROS, PFSH related to sore throat. Provider now has an assessment and RX to manage the strep throat.

Can we bill both prevent and problem visit?

Thank you

It does not sound like the provider documented enough to bill a problem visit. The patient had no complaint and this was something the provider happened to find during the preventative visit. Unless there is separate documentation above that of the well visit there would not be enough to support billing another E/M.
 

wynonna

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Hinsdale, MA
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Preventative and E & M

I am preparing for an important meeting with the physicians at an internal medicine office. Our providers do many physicals and wellness exams, and half of these they want to charge an office visit, or problem-focused visit as well.
Does someone know the exact criteria meeting the documentation requirements to bill PE with Office visit? I've heard at the office the following examples: the MD has to schedule a referral, or do additional workup, or the patient has an acute issue or voices a complaint. It would really help me to know exact language to document for the office visit code to be billed with Preventative, such as "MD is referring pt to another Dr. for a breast cyst, or is prescribing a new medicine or is changing and RX, and other such phrases. Any and all circumstances which will justify the office visit, or problem focused visit in addition to PE and which can be documented will be helpful to present to my doctors at the next meeting.
What constitutes additional workup?
What constitutes acute?
Does the pt have to verbalize a complaint, or can the MD discover it in exam? are just a few more specific questions
Thank you!
 
Messages
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I am preparing for an important meeting with the physicians at an internal medicine office. Our providers do many physicals and wellness exams, and half of these they want to charge an office visit, or problem-focused visit as well.
Does someone know the exact criteria meeting the documentation requirements to bill PE with Office visit? I've heard at the office the following examples: the MD has to schedule a referral, or do additional workup, or the patient has an acute issue or voices a complaint. It would really help me to know exact language to document for the office visit code to be billed with Preventative, such as "MD is referring pt to another Dr. for a breast cyst, or is prescribing a new medicine or is changing and RX, and other such phrases. Any and all circumstances which will justify the office visit, or problem focused visit in addition to PE and which can be documented will be helpful to present to my doctors at the next meeting.
What constitutes additional workup?
What constitutes acute?
Does the pt have to verbalize a complaint, or can the MD discover it in exam? are just a few more specific questions
Thank you!

In order to bill an office visit charge, the provider's documentation has to clearly explain what work was done for the PE and separately, what work was done to address the problem/complaint. The portion of the documentation related to the problem/complaint is what would be used to level the office visit charge. However, if the patient came in with no CC and an issue was discovered during the PE, there would have to be significant work involved when addressing the problem. Basically, a problem visit can only be billed if diagnosing/treating that problem is significantly above and beyond what would normally be treated during a PE.

On a side note to that, preventive visits are typically not subject to copays or coinsurance. When you tack on a problem visit, the patient is then subject to possible OOP costs. That's a major reason why billing a preventive visit and a problem visit together is highly frowned upon. Personally, if I went to the doctor for what I thought was a PE and ended up being charged for an office visit, I'd be pretty upset when that bill came. It's just bad business to escalate a wellness visit into a problem visit when it can, and should, be avoided.
 
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