JGGBALLEN
Networker
Hello
Question #1. Is it not appropriate to assign V70.x and any other documented problem-oriented ICD-9 codes (493.90, 300.00, 786.5) as secondary, tertiary, etc diagnosis with a preventive medicine?
Quyestion #2. auditing a preventive medicine note...is there a specific number of elements (within hx & exam & counseling) that will suport "comprehensive";
understanding the above in not the same as E&M requirments
I found some guidance on what should be documented in an effort to support the comprehensive nature/requirement but, in the note I reviewed only some were documented but, a comprehensive ROS & EXAM was done.
Hx: past illness, surgery, meds, allergy, famhx & socialhx, status of chronic conditions ---- what number of the above mentioned do I need to see documented in order to support/qualify?
Exam: ---- what number of organ systems/BA do I need to see documented in order to support/qualify?
Counseling/Guidance: nutrition, physical activity, healthy wt, injury prev, misuse tobacco, drug/alcohol, sex, STD & contraception, dental health, immunizations & screenings ---- what number of the above mentioned do I need to see documented in order to support/qualify?
Question #3: If the minimum elements are not met, can I submit 9921x (est pt 2/3 (exam & plan)). I was not sure as there will proberable not be a CC other than "presents for annual". Would the provider then get no credit for the encounter?
Your assisitance is greatly appreciated!
Thank you
Question #1. Is it not appropriate to assign V70.x and any other documented problem-oriented ICD-9 codes (493.90, 300.00, 786.5) as secondary, tertiary, etc diagnosis with a preventive medicine?
Quyestion #2. auditing a preventive medicine note...is there a specific number of elements (within hx & exam & counseling) that will suport "comprehensive";
understanding the above in not the same as E&M requirments
I found some guidance on what should be documented in an effort to support the comprehensive nature/requirement but, in the note I reviewed only some were documented but, a comprehensive ROS & EXAM was done.
Hx: past illness, surgery, meds, allergy, famhx & socialhx, status of chronic conditions ---- what number of the above mentioned do I need to see documented in order to support/qualify?
Exam: ---- what number of organ systems/BA do I need to see documented in order to support/qualify?
Counseling/Guidance: nutrition, physical activity, healthy wt, injury prev, misuse tobacco, drug/alcohol, sex, STD & contraception, dental health, immunizations & screenings ---- what number of the above mentioned do I need to see documented in order to support/qualify?
Question #3: If the minimum elements are not met, can I submit 9921x (est pt 2/3 (exam & plan)). I was not sure as there will proberable not be a CC other than "presents for annual". Would the provider then get no credit for the encounter?
Your assisitance is greatly appreciated!
Thank you