Preventive care + E/M


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I am fairly new to family practice coding. I know I can bill prev visits and E/M if there is documentation of services above and beyond the routine prev services. My question is what elements define a prev visit and how do I know when the services have gone beyond the customary routine care? If an encounter form is given with the prev service and E/M with the routine diagnosis and (for example) hypertension and hyperlipidemia, what entitles the provider to bill a separate E/M with these diagnostic codes? Would the evaluation of these diagnoses not be part of preventive care? I understand the boundaries with let's say prev and allergic rhinitis. When patients call questioning this billing, I still have a hard time explaining how the service was above and beyond the routine service. The usual statement is "Well, am I not allowed to discuss any conditions I may have with the physician? I though that was what the annual routine visit was for." I need a cut-and-dry explanation I can give of what defines preventive and what defines the additional diagnostic service.


Tulsa, OK
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Unless you are doing a Well woman exam where you have to have 7 out of 11 elements, there are no mandated, cut-and dry guidelines as to what is required on a Well exam. It's based on what the doctor feels is appropriate for the patients age.
You are correct in billing both, as long as there is significant and seperate documenation to warrant billing. I recommend my doctors complete a seperate note for the problem situation. The patients that complain about not being able to discuss conditions, well, in my opinion if you have complaints or problems, no that is not the purpose of a routine visit. That's why it is called a wellness exam. If it's something minor that is an "oh, by the way" condition or something the doctor finds while doing the exam and doesn't require much of an extra effort then it should be part of the preventative exam.
Some of my doctors don't like to make the patient come back but if the patient is very sick they will treat the illness and reschedule the well exam for another time. Sometimes they will do both and depending on the insurance (our local Medicaid will not allow a Well exam and problem visit on the same day) we bill both to the insurance.
You might want to develop a policy or some kind of handout so the patients will know a head of time they might be responsible.
Another thing too is the patient is usually scheduled for a Wellness exam, so they are put on the schedule for that time amount, but then the patient wants to discuss other issues. That's not allocated on the schedule for the visit. So now you are cutting into the next patients exam time. What if every patient did that? It usually happens anyway in a lot of appointments, but if it happens on every Well exam as well then the doctors schedule gets even further behind and now everyone is upset. The goal is to get all the patients treated completely while trying to keep the doctor on time.