Wiki Preventive care with an E/M

[Lwright01]

If a patient comes in and have a CPE ( Preventive care) done and the provider documents Atypical mole, but only wrote a referral to another provider, nut not other work up can you code a E/M?

 

[csperoni]

If all the provider did was say "hey, that mole looks odd - go see a derm", my opinion is that does not meet the requirement to bill a separate E&M with -25.

 

[keke74]

Per CPT/Preventive medicine guidelines, if a problem/abnormality is encountered in the process of performing a preventive medicine E/M service that does not require additional work then a problem-oriented E/M service should not be reported. From what you stated here, it doesn't appear that any additional work-up was done for the atypical mole other than a referral to another provider. Hope this helps!

 

[mcdream]

Separate E/M?
Let's say PCP sees patient for their yearly preventative exam.
The patient presented without any concerns/complaints.
However, during the course of the visit, the provider discovers a lump in the breast.
The patient was unaware of the lump and denies having any symptoms.
The provider orders a mammogram.
CPT guidelines state if an abnormality is discovered & is significant enough to require additional work & performance of the key components (hx &/or exam and MDM) of a problem-oriented visit then a separate E/M should be reported.
In this example cannot count the exam as 1 of the required 2 of 3 key components (hx &/or exam and MDM) because the exam is part of the annual (cannot double dip), and there is no history component as the patient presented without breast concern/asymptomatic, but can count the ordering of the mammogram as the MDM component. Documentation only supports 1 component (MDM) therefore cannot bill a separate E/M?

 

[csperoni]

Separate E/M?
Let's say PCP sees patient for their yearly preventative exam.
The patient presented without any concerns/complaints.
However, during the course of the visit, the provider discovers a lump in the breast.
The patient was unaware of the lump and denies having any symptoms.
The provider orders a mammogram.
CPT guidelines state if an abnormality is discovered & is significant enough to require additional work & performance of the key components (hx &/or exam and MDM) of a problem-oriented visit then a separate E/M should be reported.
In this example cannot count the exam as 1 of the required 2 of 3 key components (hx &/or exam and MDM) because the exam is part of the annual (cannot double dip), and there is no history component as the patient presented without breast concern/asymptomatic, but can count the ordering of the mammogram as the MDM component. Documentation only supports 1 component (MDM) therefore cannot bill a separate E/M?

A provider discovering a breast lump during a preventive exam is very likely a separate E&M. I think you may be misunderstanding current guidelines how to level E&M services. The history and exam are not required, and it is at the provider's decision and discretion whether it is required, and how extensive. 99202-99215 are leveled on either MDM or time. Time is not noted here, so you are left with MDM. The MDM components are problem, data, and risk. While you may not have a high level visit in this scenario, it seems you do have MDM that is separate and distinct from the preventive.

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

 

[kdlberg]

I agree. If you took out everything related to the preventive visit, you would still have enough left for an E/M code. New problem with uncertain prognosis (lump in the breast is listed as a specific example in most sources), none/minimal data (order of mammogram), and risk to patient would be low. I would code this as a 99213, unless the provider had documentation to support the patient had a higher level of risk.

 

[mcdream]

If no additional workup is planned (tests, labs, studies, specialist referrals), but a plan to monitor the condition is documented "follow up in 1 month for BP check", is that sufficient to support a separate E/M? (Low Complexity: acute new problem, SF Data: none, Low Risk: follow up = 99213)
PCP sees patient for their yearly preventative exam.
The patient presented without any concerns/complaints.
However, the provider discovered that the patient's blood pressure was elevated in clinic today at 145/87 with repeat 156/86. The patient has no prior diagnosis of HTN. The patient denies dizziness, headaches, SOB.
The provider discussed with patient that he should check his pressures daily at home and keep a BP log and follow up in clinic in 1 month to review log and check BP.

 

[csperoni]

If no additional workup is planned (tests, labs, studies, specialist referrals), but a plan to monitor the condition is documented "follow up in 1 month for BP check", is that sufficient to support a separate E/M? (Low Complexity: acute new problem, SF Data: none, Low Risk: follow up = 99213)
PCP sees patient for their yearly preventative exam.
The patient presented without any concerns/complaints.
However, the provider discovered that the patient's blood pressure was elevated in clinic today at 145/87 with repeat 156/86. The patient has no prior diagnosis of HTN. The patient denies dizziness, headaches, SOB.
The provider discussed with patient that he should check his pressures daily at home and keep a BP log and follow up in clinic in 1 month to review log and check BP.

To my eyes, the provider evaluated the elevated BP and came up with a treatment plan, so yes, separately billable. However, I would not agree with low risk for checking home BP and keeping a log. I would call that 99212. IF provider said "Due to elevated BP, don't take OTC decongestants" or "Increase your dose of labetolol to 40mg" or something more significant, I would then consider higher. But checking BP at home I consider minimal risk.

 

[pclaybaugh]

Thanks for this terrific thread. Issues w/preventative and an EM as well. So, the order for the US and prescription is sufficient for a problem visit. I don't feel that there is enough for a preventative on top of it. This doesn't appear to be a preventative, rather problem focused.

Chief Complaint
NP Annual, dyspareunia, abd pain and swelling
History of Present Illness
Patient presents to the clinic for a routine gyn exam. She is due for a pap smear. She is up to date on her mammogram. She is complaining today of significant pelvic pain and pain with intercourse. She has been diagnosed with a uterine fibroid in the past and is concerned that this may be her issue. She is not having bleeding.
ROS
Constitutional: No fevers, No chills, No sweats
Respiratory: No shortness of breath, No cough
Cardiovascular: No Chest pain, No palpitations, No syncope
Gastrointestinal: No nausea, No vomiting, No diarrhea
Genitourinary: Positive forpelvic pain, pain with sex
Endocrine: No excessive thirst, No excessive hunger
Integumentary: No rash, No pruritus, No abrasions
Neurologic: Normal mood and speech
Psychiatric: No anxiety, No depression

Physical Exam
Vitals & Measurements
HR: taken
HT: taken

General: Alert and oriented, well nourished, No acute distress
HENT: Normocephalic
Neck: Supple, non-tender
Lungs: Respiration: Non-Labored
Breast: No lumps, No bumps, No scars, Normal nipples, no nipple discharge
Abdomen: Soft, non-tender, non-distended
Skin: Skin is warm, dry and pink
Pelvic: Ext gen- Normal architecture and skin
Introitus- normal caliber
Vagina- normal rugae, no masses
cervix/uterus- Normal size, tender to palpation, mobile
Adnexa-tender, no palpable masses
Neurologic: Awake, alert and oriented X4
Psychiatric: Cooperative, appropriate mood and affect

Assessment/Plan
Acute pelvic pain, female R10.2
Follow up on pelvic ultrasound and treat as indicated
Ordered:
meloxicam 15 m
US Transvaginal Non-OB, Acute pelvic pain, female | Fibroids

 

[jkyles]

Agreed. I see the mention that the patient is due for a Pap smear, but no documentation that one was taken.

 

[csperoni]

Another vote for problem oriented only. I don't see PAP done, nor any preventive counseling.