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New to Auditing/Preventative E/M question

  1. Smile New to Auditing/Preventative E/M question
    Medical Coding Books
    Hi everyone.. I'm new to auditing and am currently working on an audit for a Family Practice. In the charts I'm working on, I'm coming across preventative medicine services. My question is: Are there seperate guidelines to audit the preventative E/M codes? Where can I find them? Not having much luck on the AAPC site or Google.

    Thank you!!

  2. #2
    Default Auditing preventive medicine
    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

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