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Wellness and office vist billed for routine refills?

W

wynonna

True Blue
Messages
539
Location
Hinsdale, MA
If a provider is refilling a Medication for an existing problem during a Wellness visit, for example, a statin for dyslipidemia, may we bill an office visit with Wellness? and if yes, a 99212 or 99213?
thanks
 
Routine Refills

Typically, that is part of the wellness visit. You do need the documentation above and beyond the wellness visit to substantiate the problem E/M. Using your dyslipidemia example, if the patient is compliant with their meds and their lipids are still very high, the provider may spend additional time explaining diet or change the med and explain side effects, etc. If that is the case, there would be that additional documentation that may meet requirements for a low E/M then.
 
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