Wellness/Preventative and E&M (office visit or problem focused visit) billing togethe


Hinsdale, MA
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Wellness/Preventative and E&M (office visit or problem focused visit) billing togethe

I am preparing for an important meeting with the physicians at an internal medicine office. Our providers do many physicals and wellness exams, and half of these they want to charge an office visit, or problem-focused visit as well.
Does someone know the exact criteria meeting the documentation requirements to bill PE with Office visit? I've heard at the office the following examples: the MD has to schedule a referral, or do additional workup, or the patient has an acute issue or voices a complaint. It would really help me to know exact language to document for the office visit code to be billed with Preventative, such as "MD is referring pt to another Dr. for a breast cyst, or is prescribing a new medicine or is changing and RX, and other such phrases. Any and all circumstances which will justify the office visit, or problem focused visit in addition to PE and which can be documented will be helpful to present to my doctors at the next meeting.
What constitutes additional workup?
What constitutes acute?
Does the pt have to verbalize a complaint, or can the MD discover it in exam? are just a few more specific questions.
What is the minimum that needs to be documented for a level 3? a level 4?
What are some key phrases or real-life examples of documentation which point out significantly identifiable problems that justify 99212, 99213, 99214, 99215 in addition to Preventative/Wellness Exam visits?
Thank you!