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Wiki Yearly pe

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HBULLOCK

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We have a patient who came in for his yearly physical. He happens to have multiple issues some chronic. He has mr, scoliosis, obesity, and hypotonia. My dr would like me to bill 99394 and 99214 because he addresses these issues but i don't think that is correct since he only checks the status of these and doesnt really do enough for an additional e/m. When patients have chronic illnesses that are being routinely followed shouldn't that be included in the yearly exam? Any thoughts?? Thanks :d
 
The key is did he document significant separate work for any of these problems?

For example, if he documented---- "mr-last echo 6 months ago; scoliosis, stable; obesity, increasing his exercise; hypotonia, managed by dr XXXX"---then that does not support the required significant separate work

He has to show MDM of a problem. He has to show his work took time and resources. Not for all 4 but at least for 1
 
Thats what i thought. He was just touching on all issues to be sure they were under control. There certainly wasn't significant separate work on them. Thanks alot! :d
 
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