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Wiki Preventive Medicine Coding

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spenning.sp@gmail.com

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Little Rock, AR
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Good Morning:

I have a question concerning chart documentation for use of Preventive Medicine code 99391 in pediatric clinic. Physician does not document the ROS. Physician states it is not necessary to document the ROS because it is wellness.

I do not find in CPT stated as not documenting the ROS - simply stated as "gender appropriate history, examination, counselling /anticipatory guidance/risk factor reduction intervention, and the ordering of laboratory/diagnostic procedures"...

I would appreciate any help in finding some documented support that the ROS needs to be documented for preventive medicine codes or does need to be documented to use these codes.

Thanks for helping,
Sherry Pennington, CPC
 
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