Preventive + E/M

nc_coder

Expert
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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.
 

ewinnacott

Guru
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Puyallup, WA
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It basically all depends on how good your doctor's documentation is and if you can actually pull out elements for an office visit along with a preventative visit. An example of this would be if the patient comes in for a preventative exam but also is treated for a cold with meds. You would bill the preventative visit plus a 99212-25 for the E/M
 
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