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Wiki Preventative Exam w/ OV...

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cmedina969800

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I know there are many resources out there about a problem-oriented w/ a preventative exam. I'm trying to gather some thoughts about what is considered significant and separately identifiable.

Here is the situation in a nutshell...

Pt comes in for a preventative exam.

Pt also presents w/ a new complaint: SOB w/ excercise, he feels he cannot improve his physical performance w/ the SOB

Complete ROS and Exam are done (due to preventative exam scheduled)

Provider diagnosis pt w/ exercise induced bronchospasm

Provider prescribes inhaler for exercise induced bronchospasm.

Would this be considered significant and separately identifiable?

In my coding training I was told that some of the "preventative exam" could overlap in a problem-oriented exam. Any thoughts on this?
 
prev with ov

I was always taught, that if after you have pulled what you need out of the doucumentation to support the preventative service, then you can bill for the office visit E/M if there is anything left over in the HPI,ROS and exam that is directly related to the problem combined with the MDM. I am assuming that the patient is established, which you would only need the 2 of 3 anyway. I hope this made sense to you, it made sense in my head! :)


Angelisa Wagner CPC
 
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