Preventative Visits

lorrieb23

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I'm really confused here. Hope someone can help. How do you bill for a preventative visit (ie: 99396) when it should include a comprehensive history and exam when the requirement for a comprehensive physical includes a CC and 4 or more elements of HPI or status of 2-3 chronic conditions? See notes below. And what if the patient has no chronic conditions? I've run into that situation before also?

Subjective:

Chief Complaints:
1. Annual phy.

HPI:
Patient History:
patient has been doing well.

ROS:
General ROS:
Constitutional: Negative for:, chills, fatigue, fever, night sweats, Negative for:, chills, fatigue, fever, night sweats. Dermatology/Integumentary: Negative for:, rash, warmth, itching. No other significant findings. HEENT: Negative for:, Eye:, pain, visual changes, Negative for:, Eye:, pain, visual changes. Resp/Pulmonology: Negative for:, cough, dyspnea on exertion, shortness of breath, Negative for:, cough, dyspnea on exertion, shortness of breath. Cardiology: Negative for:, chest pain, palpitations, Negative for:, chest pain, palpitations. Gastroenterology: Negative for:, abdominal pain, blood in stool, nausea, vomiting, Negative for:, abdominal pain, blood in stool, nausea, vomiting. Genital/Urinary: Negative for:, dysuria, flank pain, Negative for:, dysuria, flank pain. Musculoskeletal: Negative for:, weakness, muscle pain, Negative for:, weakness, muscle pain. Neurology: Negative for:, dizziness, headaches, loss of coordination, memory changes, numbness, speech changes, swallowing problems. Psychology: Negative for:, irritability, poor concentration, poor concentration, suicidal thoughts. Hem/Lymph: Negative for:, appetite changes, fatigue, Negative for:, appetite changes, fatigue. Endocrinology: Negative for:, polydipsia, weight loss, Negative for:, polydipsia, weight loss.


Medical History: Vericosal 1992;, Sinus 1985;, Tonsils 1975;.

Hospitalization/Major Diagnostic Procedure: Denies Past Hospitalization.

Family History: Mother: deceased, Mother: CAD Mother: HyperlipidemiaFather: deceased, Father: CAD Father: Hyperlipidemia Father: Hypertension Father: CAD 76 (onset)Brother 1: Brother: Asthma Brother: Blood disease Brother: Hyperlipidemia Brother: Mental illness


Assessment:

Assessment:
1. Annual physical exam - Z00.00 (Primary)
2. Hypercholesteremia - E78.0
 

stephanie.moore@wdhospital.com

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This documentation only has an ROS I do not see an exam. I would take a look at the Preventative Med Guidelines in CPT and when they refer to "comprehensive" nature of the Preventive Services codes 99381-99397 reflects age appropriate and gender appropriate history/exam and is not synonymous with the "comprehensive" examination required in E&M codes 99201-99350. In addition there is no CC required for Annual PE's
 

lorrieb23

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Thank you.

Thanks Stephanie for your quick reply. I hope you can help me a little more.

I didn't include the exam part of the note, but it indicates 9 organ systems for a comprehensive exam. I found this quote:

"The E/M service includes a comprehensive history and examination appropriate for the patient's age and gender along with counseling and guidance for prevention of risk factors."

Is there enough history documented to support billing a 99396?

And what about the 'counseling and guidance' ? Is that a requirement in order to bill an annual?
 
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