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.
 

nhenderson

Networker
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From what I have read on this subject the preventive medicine visit is age and gender appropriate hx, exam, counseling, guidance, risk reduction, intervention and order of lab & diagostic procedure. If the patient is 65 and has hypertention it seems reasonable to include that in the preventive visit and the ordering of test would be appropriate if needed. If the 65 yr old patient complains of knee pain at the visit and the physician does a muscle skelatal hx, exam and mdm this would be above and beyond the preventive medicine coding. I hope that helps
 
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