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Preventative Vs. Problem Visit

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I have a patient who was seen for an annual examination.

CC: No physical c/o - here for yearly PE
HPI: Feels fine
PMH: elevated cholesterol, elevated glucose, Reviewed annual health update form, ROS incluses Head, Eyes, Nose, Neck, Resp, cardiac throat, breasts, GI, all normal except a notation of decreased hearing.

Detailed examination with the notation of Encorged Mucosa and LE Pulses decreased, Fine Tremor,

Assessment: elevated glucose, decreased hearing, elevated cholesterol, allergic rhinitis.

Plan: CMP and Lipid Panel ordered along with Baby ASA qd.

No RTC on note, on bill doctor noted 12 months. least year's conditions of PVD, Skin Lesions and Enlarged Prostate were not addressed.

Last year's RTC was one year.

I dont think there was a significant new problem, no seperate documentation of an evaluation and managemetn service, patient had no complaints. There are a couple of active disease processes, but I think it is preventative, however there is no documentation of counseling for risk factors, etc.

What do you think? :)

The patient does have Medicare - which brings about the question of ABN's. I believe I would bill with a GY because it is statutorily excluded, I would use a V code as the primary dx and the other codes as additional dx. Thoughts?


Best answers
preventative, hopefully the pt has a secondary or does sign an abn. We use GY even if there is an abn because like you said its statutorily excluded.