Question Travel Consultation along with Well Exam

[vtailor]

If a patient is presenting for Well Child Visit during which travel consultation is done, how to bill for it. Should an E/M reported along with Well Child exam. What documentation in medical record is needed to satisfy additional visit for travel consultation.

Thank you.`

 

[lgardner]

what was done during the 'travel consultation'?
did the pt receive any vaccinations or meds?

 

[vtailor]

No meds were given. Parent refused Typhoid vaccine.

 

[lgardner]

I don't think that would be separately billable.

 

[vtailor]

In other scenario, say if medicine mefloquine was prescribed, then it would qualify for E/M (99213).

 

[lgardner]

yes. as long as the documentation supports it and you can, clearly, pull out the separate elements for the E/M (outside of the wellness visit).

 

[vtailor]

Thank you very much. But, I have more question. In order for us to bill E/M visit during a Well Exam, if the patient didn't complain about anything, but on exam, if a provider sees a rash which requires treatment and gives a prescription strength medication, can we bill E/M in addition to preventive exam.

So doctor has not documented the problem in HPI, but in Exam portion she has documented dermatitis and in A&P diagnosed with perioral dermatitis and prescribed medicine. Can it be coded as 99213 in addition to preventive visit. As there is no CC or HPI regarding this, can it be billed? So the problem is acute and prescription management. Data none. CC none.

 

[lgardner]

if the problem is discovered on exam, and treated, you can bill an E/M. just make sure it is documented in the exam.

I, also, tell my providers that best documentation practice would be for them to mention in the HPI that a "rash was discovered on exam", but it doesn't, necessarily have to be in the HPI.

 

[vtailor]

Thank you very much.