I work for several Internal Medicine and Family Practice physicians. We have some doctors who are very clear and dictate a separate section in the same chart note regarding the preventive portion of the visit. However, some just dictate the whole visit as they performed it, which sometimes isn't so nicely compartmentalized. Therefore, I believe as a coder if I am able to sort out the problems from the preventive visit just by reading the note, then both are supported and billable. I have actually taken a highlighter to a photocopy of a chart note and identified the portions of the visit that were directed at the patient's problems and support the level that I am billing, just to make it clear for the payer. What is not hightlighted is the preventive portion of the visit, which has no "component" requirements per se. However, there should be documentation remaining that supports age appropriate history, exam (usually head-to-toe) and risk factor reduction counseling, screening lab orders, etc.
Kay, CPC, CCS-P
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