Wiki Preventative visit with additional E/M

[tmcknight86]

I'm getting some push back from a few providers on their documention on an encounter when a kid comes in for a well visit and they find something else that needs to be address. They keep writing "see well visit" and putting just a few thing in the encounter note. I remember reading, or maybe it was in a webinar, that this doesn't cut it. Can someone point me in the write direction of this information so I can show them?

 

[Pam Warren]

So what you're saying is that the E&M visit that they want to bill isn't separately documented and significant from the well visit note?

The use of the -25 modifier for that additional E&M visit, requires the provider to separately support relevant history/exam and a separate medical decision within the note to allow for billing that additional E&M code with the -25 modifier appended. They don't need an additional note per se, but the documentation should be able to be carved out of the note in a way that you can tell that a problem was addressed and that there was a clinical care decision made to support an additional charge. I would discourage the use of 'see well visit', because that implies that it's all the same note. They can document their well child check note, and in a separate paragraph, summarize the problem, document problem/status/treatment within the medical decision making and assign a diagnosis and plan.