That's a good question and one we have discussed also. My understanding (and please correct me if I'm wrong), is that if it's significant enough that you have to do more than just mention it and do a maitenance lab or something of that nature. For example female patient comes in for her yearly preventive pap and such. She also is hypothyroid. Only medication she takes is synthroid. Doc does the pap, asks patient all pertinent questions for her exam and then she says, I need a new script for my synthroid. He gives her that, but in my opinion this is not enough to code a separate E/M because there weren't any problems with this. It's a known condition, it's stable, nothing abnormal. Tests done are the yearly tests needing done. This to me should just be a preventive visit. On the other hand, if the patient has her pap, Doc asks patient all pertinent questions and then she says, oh yeah, I have been cold all the time, my skin is extremely dry, I am tired. Don't know what's going on, and I need a script for my synthroid. Doc then has to delve into her symptoms to find out what's going on. Is it due to her hypothyroid, is she having other problems that they just don't know about yet? This then would be a separate and identifiable E/M (documented of course) because it's something above and beyond the normal for this patient.
Anyone else have thoughts on this?
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