Wiki well visit with separate E/M

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dsmith06351

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The Doctor wants me to audit office notes from a well visit to see if her notes support a seperate E/M code. Is there a book or some sort of reference that would help me with this? This is one are that I am unsure of.

Thank You
Denise Smith CPC-A
 
Start with the CPT guidelines

I would start by reading the guidelines for the Preventive Medicine Service codes. I have the CPT AMA book and it's on page 29. In order to bill for a seperate E/M there must be significant/seperately identifiable work that goes beyond the work of a prevenative service.
Hope this helps!
 
I have read the guidelines. My question on this particular visit is the doctor did a well visit exam for a 14 yr old. After the exam the doctor spent 25 minutes discussing a new dx of anxiety and depression. They discussed the causes the symptoms and then the doctor recommended counselling. How can the doctor bill for the additional time spent.


Thank You

Denise Smith CPC-A
 
dsmith06351 said:
I have read the guidelines. My question on this particular visit is the doctor did a well visit exam for a 14 yr old. After the exam the doctor spent 25 minutes discussing a new dx of anxiety and depression. They discussed the causes the symptoms and then the doctor recommended counselling. How can the doctor bill for the additional time spent.


Thank You

Denise Smith CPC-A
Click to expand...

If this were one of my physicians, I would reccommend that they document a seperate note dealing with the anxiety and depression (if it's been current enough to remember). It sounds like your physician spent time performing counseling and/or corrdinating care. Visits can be coded based on time if more than half of the total visit time is spent on counseling/coordination of care. If he/she can remember how much total time was spent dealing with the anxiety/depression problem and if more than half of that time was spent in counseling/coordination of care, then there would be a good case for charging an E/M in addition to the preventive code (but this always depends on the documentation).
In the real world, some insurance companies may not pay for both visits, so you may want to check with your carriers to see if they have a policy on this.
 
Thank You,

I find it difficult some times to pick apart the notes to determine what can be counted as a separate charge.

Denise Smith CPC-A
 
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