Wiki Well Visit + Sick Visit

[tg]

Hi. When I am coding a well visit, there is usually a comprehensive history and exam documented. My question is if I am coding a sick visit in addition to the well visit for the same encounter, am I allowed to use the ROS and Exam for the sick visit in terms of counting the systems, etc.? If I do I will probably end up with a 99215 each time which doesn't really make sense. Any help would be appreciated. Thank you!

 

[mitchellde]

you cannot count the elements reviewed for the wellness as elements of the sick visit, if you cannot clearly identify the key elements that pertain only to the sick part then you cannot bill anything other than the preventive.
For ICD-10CM when a patient presents for a scheduled wellness visit, they cannot also have a symptomatic problem, the ICD-10 CM codes for the general exam have an excludes 1 note for signs and symptoms which indicates that they cannot be coded together.

 

[tg]

I see. Because the preventive exam is so extensive and so many systems are reviewed and examined though, won't they overlap?

 

[mitchellde]

yes and that is why you cannot count those elements that overlap twice they count towards the primary reason for the encounter which preventive, that leaves very little to count for the sick portion, and if there are not two separate chart notes it is most often impossible to be able to pick out the elements exclusive to the sick portion in the event of an appeal for payment.

 

[MikeEnos]

You don't need a separate chart note, I often see an additional paragraph at the beginning that addresses the problem(s), something to the effect of: "Of concern today, the patient does complain of intermittent left knee pain with swelling after doing yardwork this weekend." That is sufficient for the history. As you addressed earlier, the exam can't really be counted since a complete physical is already being done. Since you only need 2 of 3 key components, the final factor is the medical decision making complexity. So in the assessment and plan it should indicate if over-the-counter drugs or prescription drugs are given, if any tests are done, referrals to see a specialist, etc. That will help you determine the medical decision making complexity for the 'problem-oriented' portion of the visit. That's not part of a normal preventive exam.

Of course any minor or incidental findings are included in the payment for the preventive exam. Only something requires extra work (even if it is just significant cognitive labor) should be billed separately. Make sure that is clearly documented.

 

[tg]

So I guess the history level will always be Problem Focused since I can't include the ROS and if it is a new patient, I won't be able to code the sick visit in addition to the well. Thank you all for your help.

 

[MikeEnos]

No, Tovy.... the statement that I used as an example would be sufficient for at least an expanded problem focused history.

_______________________________________(timing)____(location)_____(associated signs)____(context)___(duration)
Of concern today, the patient does complain of intermittent left knee pain with swelling after doing yardwork this weekend
____________________________________________________________________________________________________

HPI - Extended (5)
ROS - Extended (2) musculoskeletal and cardiovascular
PFSH - None

 

[tg]

I'm sorry I'm not seeing the ROS. Bearing G.J. Verhovshek's article on "douple-dipping" in mind, it doesn't seem that the example you gave has enough examples per system to be counted in the ROS in addition to the HPI. Am I incorrect?