Although there are no official, specific documentation guidelines for these services, based on recommendations from the AMA, the American Academy of Family Physicians, the U.S. Preventive Services Task Force, the American College of Physicians Internal Medicine, and the American College of Obstetrics and Gynecology, here is a breakdown of the information you should see documented in the review of a preventive medicine service based on the patient’s age and gender:
Well Baby Visits – Birth to 2 Years
History: Past illnesses, surgeries, medications, allergies, in utero/birth history, family and social histories
Exam: Hearing for newborns, weight, length, head circumference, head, chest, abdomen, genitalia, neck, extremities, eyes, ears, nose, throat (ENT), cardiovascular, respiratory, skin, neurological
Counseling/Anticipatory Guidance: Safety, health, nutrition, development, immunizations, injury prevention
Risk Factors: Age appropriate developmental and behavioral assessments
Screening Services: Hemoglobin or hematocrit once between 9-12 months, phenylketonuria (PKU) screening, oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride, hearing screening before one month of age, screening for sickle-cell disease
Well Child Visits – 3 to 10 Years
History: Past illnesses, surgeries, medications, allergies, family and social histories
Exam: Blood pressure, vision screening, hearing screening, height, weight, body mass index (BMI) with percentile for age, eyes, ENT, cardiovascular, respiratory, gastrointestinal (GI), genitourinary (GU), musculoskeletal, skin, neurological, psychological
Counseling/Anticipatory Guidance: Safety, injury prevention, health, nutrition, development, immunizations, screenings
Risk Factors: Age appropriate developmental and behavioral assessments
Screening Services: Screening for obesity in children 6 years and older, vision screening
Well Child Visits – 11 to 18 Years
History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions
Exam: Blood pressure, vision screening, hearing screening, height, weight, BMI, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological
Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, avoidance of tobacco, alcohol and drugs, sexual behavior and sexually transmitted diseases (STD), dental health, mental health, immunization, screenings
Risk Factors: Hypertension, hyperlipidemia, coronary heart disease, depression, eating disorders, emotional, physical, or sexual abuse, problems with learning and school
Screening Services: Chlamydia for sexually active females, depression, obesity, HIV
Adult Visits – 19 to 39 Years
History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions
Exam: Blood pressure, height, weight, BMI, breast exam for women, depression screening, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological
Counseling/Anticipatory Guidance: Nutrition, family planning/contraception, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, dental health, mental health, immunizations, screenings
For Women: Breast cancer and self breast exams
Screening Services: Cholesterol every five years beginning at 20 years of age, chlamydia for sexually active women under 25 years of age, cervical cancer, HIV
Adult Visits – 40 to 64 Years
History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions
Exam: Blood pressure, height, weight, BMI, depression screening, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological
Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, contraception, dental health, mental health, immunizations, screenings
Screening Services: Cholesterol, diabetes, colorectal cancer beginning at 50 years, HIV
For Women: Breast cancer, cervical cancer
For Men: Prostate cancer beginning at 50 years
Adult Visits – 65 Years and Older
History: Past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions
Exam: Blood pressure, height, weight, BMI, hearing screening, depression screening, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological
Counseling/Anticipatory Guidance: Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol, and drugs, sexual behavior, dental health, mental health, fall prevention immunizations, recommended screenings for age/gender
Screening Services: Cholesterol, diabetes, colorectal cancer
For Women: Breast cancer, cervical cancer, osteoporosis beginning at 65
For Men: Abnormal aortic aneurysm (one time for men 65-75 years with history of smoking), prostate cancer
What Services Must Include
Checking the status of chronic conditions and refilling on going prescriptions is expected during an annual preventive exam and do
not warrant the billing of a separate problem-oriented E/M service. If a chronic condition is not being well controlled, however, and decisions are being made as to how to treat the patient to improve control (changing the dosage of medications, changing to a new medication, etc.), this may substantiate a separate problem-oriented E/M service. For example, more work is done (and documented) than what is performed normally during an annual preventive exam.
Remember: These are recommendations, only; the patient’s needs, history, and risk factors determine the extent to which counseling, anticipatory guidance, and screening services should be performed, based on the provider’s clinical judgment. For example, a female with a family history of breast cancer may need a screening at an earlier age than typically recommended. What’s important is the documentation should include what counseling and anticipatory guidance was provided to each patient, as well as the screenings that were discussed and ordered or offered, should the patient decline. The documentation should very clearly show that the elements of the annual preventive service were met.
Hope this helps!