Wiki Preventative visit with additional coding

[nataliewilliamsmendoza@gmail.com]

I have a medical chart where patient came in for "well woman" exam; however medications were ordered for Asthma, Anaphylaxis, and Seasonal allergies. Provider goes over the asthma briefly in the subjective part of the encounter - then goes over all 3 within the "plan" part of the encounter - ordering medications. The guideline states that you can also code a "regular" visit if a preexisting condition is addressed during the encounter. What instances would justify a "significant - separately identifiable" service? I understand that this one is sort of borderline - but I definitely need some guidance on the coding aspect for these type visits.

 

[csperoni]

I think a good way is to think of each item as either counting toward the well woman, or toward 99202-99215. Code the E/M based on what's left after eliminating the well woman portions.
I have heard of some practices having a policy if a patient is there for well woman (or annual for PCP), the provider does not address the other issues, and patient must return for another visit. That certainly makes it very cut & dried from coding, but I personally don't think it's great from a customer service perspective.