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well visit and counseling

  1. Default well visit and counseling
    Medical Coding Books
    (coded as 99401 and 99394)

    The provider writes--40 minutes was spent face-to-face. Over 50% of this time was spent in counseling and education with mother and patient, as well as patient separately.

    I know we cant use the 99401-99404 because its included in the well visit. But, could we use the extra time spent in counseling and use 99214 in addition to the well visit instead??

    Any thoughts would be greatly appreciated!

  2. #2
    Greeley, Colorado
    Based on the documentation provided, I would say no. It doesn't specify what the counceling was for. Is there a significant separately identifiable problem oriented E/M service in the documentation?
    Lisa Bledsoe, CPC, CPMA

  3. Question e/m and counseling
    in the chief complaint the documentation states:
    Requesting advice on breast reduction
    ring worm
    (discussed sex, std, contraception, and menses with pt in private)

    And after the well visit documentation and in the assessment and plan the documentation states:

    Discussed: Dtap, Gardasil, and menactra
    Discussed: Approach to breast reduction, consult to plastics in future, and proper support fitting at a department store
    Discussed Menses, OCP, and Fe supplementation
    Reproductive health issues, drug use, school, planning for the future and nutritional advice, helmet/pad use, conflict resolution without violence, avoidance of weapon use, seat belt use and driving safetly (alcohol related).

    I can see that it should just be included in the well visit but also it seems like the provider spent above the normal time with the patient in counseling and you could defend an additional service be billed based on the time. But im not sure what diagnosis code you would use.

  4. #4
    Milwaukee WI
    Default Ring worm
    The only thing I see in your chief complaint that would warrant a "sick visit" is Ring Worm.

    Do you have enough documentation to code THAT portion of the encounter separately?

    Otherwise your counseling is all preventive and part of the your well visit.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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