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annual exam on medicare patient

  1. Default annual exam on medicare patient
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    When a physician sees a medicare patient and his documentation states "patient is here today for their annual examination" and then goes on to state "has a history of HTN, hypothroidism, & diabetes" and really is a follow-up on these conditions, should this be coded as a preventive or problem visit?

    Also, if a medicare patient is seen and the physician documentation states "here for a yearly follow-up of her HTN and hyperlipidemia" is it correct to code this as a problem visit?

    Would like a clarification on these, please. Thanks.

  2. #2
    Depending on what the physician did w/ the chronic conditions we may actually split-bill. If the physician spent additonal time reviewing meds, ordering additonal testing, counseling the pt on their condition, I may bill an E&M in additon to the prevenative exam. However, if he/she mentions it as part of their history, nothing to really address, no changes in anything, then I consider it prevenative.
    adrianne, cpc

  3. #3
    Greeley, Colorado
    I agree with Adrianne. If it states yearly physical, annual, etc; and no changes are made to the treatment of the chronic illnesses (ie all stated as well controlled), and the provider performs a wellness oriented physical exam, counseling, renews prescriptions, etc...I consider that as preventive.
    Lisa Bledsoe, CPC, CPMA

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