I am not aware that the documentation needs to be separate. If you have some documentation guidelines that state that I would be interested in reading them. I have doctors that "split bill". I believe you called it "carve out". Medicare does require you to subtract the problem visit charge from the preventive charge.
CPT states: If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate code (99201-99215) should also be reported.
Most of the time the physicians I work for meet the additional work in the history key element when working with chronic conditions and I just "count" the elements related to those conditions in history. It's hard to split a PE when it is suppose to be "comprehensive" in nature anyways. Again, usually if an abnormality in the PE is discovered than the provider would go back to history and ask additional questions, etc. regarding the abnormal finding. But this is the way I view the guidelines and how I apply them. I an interested in hearing others viewpoints.
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