Here are the guidelines used to determine when to bill a Preventive & E/M on the same date of service.
It is not uncommon to discover problems during the course of an encounter for preventive medicine. The complexity of the Medical Decision Making (MDM) for the problem or pre-exsisting condition determines if an E/M should be billed in addition to the preventive CPT code.
If the problem is significant enough that it requires the performance of key components then the service may be reported in addition to the preventive code. Example: 99213 or 99214
If the problem or pre-exisiting condition does not warrant significant work or effort it would not be appropriate to report a seperate service.
Example: 99211 or 99212.
In addition a E/M service requires a Chief Compliant, so if there is not a documented cheif complaint the E/M service would not be supported. The refilling of mediciations for established diagnosis would not support billing an E/M service in addition to the preventive service.
Seperate documentation is not required but strongly recomended. Each CPT billed should have it's own documentation to support billing the service.
Hopefully this answers your question. Have a great day.
Allison L. Wickham, CPC, CEMC
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