There are no separate guidelines that encompass these codes (99381-99397). When auditing these services I review the chart by the definition as described by CPT.
"Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures" (AMA CPT 2010)
I make sure an age/gender appropriate history and exam are conducted and documented. If you don't have a clinical background, good communication with your clinical staff can help you develop paramenters for age/gender appropriate H&P for auditing.
The second part is auditing the record for the documentation of the counseling and risk factor reduction. For example, if it is a teenager are they discussing birth controol and seat-belt habit? For a middle aged woman it may be a discussion about monthly self breast exams.
Hope this helps!
Helen Avery, CPC, CPC-I, CHC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join