I'm hoping that I can get someone to respond to either agree or disagree and why on either counts. This regards the sometimes contraversial coding scenario of Preventive and E/M on the same day on patients that are chronically ill but have been stable.

The crux:
An E/M, especially, a level 4 is difficult to support in addition to a Preventive Medicine. A Preventive Medicine visit is already comprehensive by nature, since it includes a complete H&P. It can be difficult to extract that which was problem-oriented on a chronic-stable patient from that which was already going to occur (a complete H&P). Some insurances, medical industry references, seminars, etc, think that there needs to be a significant problem that is new or an established problem that is worsening or failing to improve with the current plan and/or treatment. Many believe that this was also the intention of the AMA when adding that scenario to the Preventive Medicine code nomenclature. Most of of the patients with 3 or more chronic but stable illnesses are being seen as level 4s on every interval follow-up visit based on Hx and MDM, without need for a detailed or even comprehensive exams.

I developed the following document and submit it for your review, that I think fit these clinical scenarios: Again I desparately need feedback on the subject...
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Preventive vs. Problem visits or Both


· A Preventive Medicine visit is a service requested by the patient. It can be recommended but the patient can decline any non-covered service. That does not mean that a “head-to-toe” exam cannot be performed as deemed medically necessary.


· If the reason for the visit is for a complete H&P for chronic illnesses, a problem-oriented E/M code should be billed. A Chief Complaint example would be, “follow-up of illnesses”, accordingly. A complete H&P would be performed including HPI. Diagnostic tests may be performed based on medical necessity and referenced to corresponding problem-oriented diagnoses codes. Screening tests may be performed and referenced to the corresponding screening V-code for tests. Age and gender appropriate counseling, anticipatory guidelines, and risk factor reduction interventions may still be part of this visit. The charge ticket would have the problem-oriented diagnoses codes and any screening V-codes corresponding to screening tests performed.


· If the patient scheduled a Well visit, that is, Preventive Medicine is the reason for the visit, however, chronic or acute illnesses become the predominant focus, it may be appropriate to bill an E/M, instead of the Preventive Medicine code. The CC and/or Hx may indicate that the reason for the visit was Preventive but problems became the focus. The HPI should include problem-oriented documentation. Age and gender appropriate counseling, anticipatory guidelines, and risk factor reduction interventions may still be part of this visit. Diagnostic tests may be performed based on medical necessity and referenced to corresponding problem-oriented diagnoses codes. Screening tests may be performed and referenced to the corresponding screening V-code for tests. The charge ticket would have the problem-oriented diagnoses codes and any screening V-codes corresponding to screening tests performed.

· If the patient scheduled a Well visit, that is, Preventive Medicine is the predominant focus of the visit; it is appropriate to bill only the Preventive Medicine code. The CC would be “Preventive Health Exam”. Preventive Medicine includes an age and gender appropriate H&P, counseling, anticipatory guidelines, and risk factor reduction interventions. Screening tests may be performed and referenced to the corresponding screening V-code for tests. Diagnostic tests may be performed based on medical necessity and referenced to corresponding problem-oriented diagnoses codes. The charge ticket would have the Routine Health Exam code, V70.0, any screening V-codes and any problem-oriented diagnoses codes corresponding to the diagnostic tests performed, accordingly.

· If the patient scheduled a Well visit, that is, Preventive Medicine is the reason for the visit and an abnormality or preexisting problem is significant enough to require additional work to perform the key components of a problem-oriented E/M code, the E/M service should be separately identifiable, well documented and may be billed in addition to the Preventive Medicine code. The CC would be “Preventive”. The Hx would include the HPI and a notation that both are being addressed in this visit. An age and gender appropriate H&P, counseling, anticipatory guidelines, and risk factor reduction interventions should be performed and documented. Screening tests may be performed and referenced to the corresponding screening V-code. Diagnostic tests may be performed based on medical necessity and referenced to corresponding problem-oriented diagnoses codes. The charge ticket would have the Routine Health Exam code, V70.0, any screening V-codes and problem-oriented diagnoses codes corresponding to the E/M code and the diagnostic tests performed, accordingly.

· A Preventive Medicine visit is already comprehensive by nature, since it includes a complete H&P. It can be difficult to extract that which was problem-oriented on chronic-stable problems from that which was already going to take place. Some insurances, medical industry references and seminars infer that there needs to be a significant problem that is new or an established problem that is worsening or failing to improve with or without treatment, or even if the plan is to continue a current treatment and to watch.

· The CC or Hx and A/P should correspond with the charge ticket, in charges marked and diagnoses and V-codes referenced no matter the reason for the visit or the payer.

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Again, I would like to hear your opinion on this subject.

Brevity is not my forte, so I appreciate you taking the time to get to the bottom of this email.

Sandy Adams
Internal Auditor
615-284-2224 ext 2352