Wiki Vision with AWV

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YessieM

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A coder and I are not seeing eye to eye when it comes to billing a vision exam with an Annual Wellness visit. The note does not warrant for a vision exam I believe the nurse just did an extra exam out of habit. I personally will not bill as it was not necessary. The other coder states she wants to bill out this service as this was performed. She states she does it all the time.

I would like another opinion in reference to billing this service.

Thank you,
 
Vision Exam

What type of vision exam was performed and during the AWV this is required unless documented to show a vision exam was performed within the last twelve months. To bill separately the documentation needs to support the charge.

Cheryl
 
Cpc-a

I agree with Cheryl. You can only bill for what is documented. If the exam was not documented as being performed then you can not bill. You need the hard proof. That's why ICD-10 is going to be so much more difficult for physicians. You think you had a problem with this sinario just wait. The physicians documentation has to change drastically. You will be querying like you never did before.
 
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