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Preventative visits

  1. #1
    Kansas City, MO
    Question Preventative visits
    Medical Coding Books
    Are there any audit tools out there for PREVENTATIVE visits?

    I see alot of these with great exams...but alot of them lack in documentation of the other components...such as the anticipatory guidance.

    What is enough, and what isn't...and do any on you ever consider billing a Well visit with an -52? Is it all or nothing?


  2. #2
    Mobile, Alabama
    Default Preventive visits
    I don't think any actual audit tools exist since what is included in the preventive care codes is so varied. Even with a patients the same age and gender, things addressed at each of their visits could be quite different. CPT explains that the codes cover an "age and gender appropriate history and exam" and that these are NOT synonymous with the comprehensive history and exam described in the E/M guidelines for other codes. The counseling is going to differ as well. A CPT Assistant article in July 2009 says in part......

    "The codes for initial and periodic preventive medicine E/M services are categorized by patient age. This is mainly because the types of preventive services provided in these visits vary and are directly related to the age of the patient. For example, preventive medicine E/M services for a 28-year-old woman may include performing a pelvic examination, obtaining a Pap smear, breast examination, and blood pressure check. Counseling may be provided regarding diet and exercise, substance use, and sexual activity. A preventive medicine E/M service for a 13-year-old girl who is an established patient may include, a scoliosis screen, assessment of growth, development, and behavior, and review of immunizations. Anticipatory guidance may be provided to the adolescent regarding good health habits and self-care, including avoidance of drugs, alcohol, and tobacco, sexual safety, and other peer-pressure issues such as, how to reduce the health risks associated with sexual activity and the importance of educational activities and social interaction."

    As for the 52, no I wouldn't think that would be an appropriate modifier, but that's just my gut feeling. I've certainly never read anything indicating that it would be. A patient either has a problem (i.e., medical necessity) or they don't (i.e., "a check up") and if they don't, then the visit is preventive care.

    In the past, when I have audited a chart note that doesn't seem to be as comprehensive as I think it should/could be, I haven't counted it against the provider but I have used it as an opportunity to exchange thoughts on what they view as "comprehensive" and how that might differ on what I consider comprehensive.

    Barbara Burgess, RN, CPC, ACS-EM, PCS

  3. Default Bev Strube, CPC, CPC-H, CPC-I, CEMC, COBGC
    I agree with Barbara. I currently work as an auditor. We have an audit tool (which we cannot share) that was compiled from various physician specialty groups (American Academy of Pedicatrics, American Academy of Family Physicians, etc.) recommendations. Preventive services are terribly difficult to audit.

    We decided never to append modifier -52. The practitioner either meets the criteria for the code or they don't. I worked in denial management for a few years before I became an auditor and modifier -52 simply confuses payers when appended to preventive service codes.

  4. #4
    Kansas City, MO
    Thanks ladies. Bev, you did say that they either "meet the criteria for the code or they don't". I understand you cannot share your audit tool, but could you elaborate, maybe by giving an example. CPT says "Codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions...",would you interpret this to mean it is required?


  5. Default
    I have a question regarding well exams as well. This is documentation for a 55 year old female who came in for a Pap. The physician failed to document that he did collection for Pap. But aside from that, does this meet criteria for a well visit code? 99396? My gut says it's not comprehensive enough but I don't know what else to charge because it's definitely not a sick visit.

    Chief Complaint: Well Women/Pap

    Vital Signs

    Temperature: 98.4 degrees F (oral)
    Pulse rate: 70
    Pulse rhythm: regular
    Respirations: 20
    Blood Pressure: 146/90 mm Hg

    History of Present Illness

    General HPI
    Pt assymptomatic - her for routine pap and breast exam - pt does not routine ly examine her own breasts - advised about same -

    Review of Systems
    General: Denies see HPI, fevers, chills, sweats, anorexia, fatigue, malaise, weight loss, headache.

    Physical Exam
    General appearance: well nourished, well hydrated, no acute distress

    Breast inspection: no asymmetry, skin changes, or nipple discharge
    Breast palpation: no masses or tenderness
    Breast Exam: Normal

    External genitalia: normal, no lesions or discharge
    Urethra: no discharge
    Bladder: no cystocele
    Cervix: normal appearance, no lesions, no discharge
    Uterus: normal size and position, midline, mobile
    Adnexa: no masses or tenderness


    Added new problem of PHYSICAL EXAMINATION (ICD-V70.0)


  6. #6
    Looks like a preventive exam to me, but I'll be curious to see other responses!

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