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Routine visit

  1. #1
    Question Routine visit
    Medical Coding Books
    I have an issue i just want to make sure i am handling correctly. A patient comes in for their yearly physical. Mom states no current issues or complaints. Physician does the exam and finds the patient as an rom. Are we allowed to bill for the e/m along with the pe? I was told unless a complaint is issued by parent/patient we cannot bill for the sick e/m since it was found during the pe? Anyone know about this?? Thanks :d

  2. #2
    Default E/M and sick visit on the same day
    From a pure coding perspective, the guidelines for billing an E/M service in addition to a preventive service are spelled out under the Preventive Medicine Services section in the CPT 2007 book. The guidelines state; “If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.

    Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service.” The key to adding an E/M service to a preventive service is the significance of the problem, the amount of work required at that visit to deal with the problem, and how clearly this is documented in the patient chart.

    Side note: not all payers follow these rules. You can bill both, but some payers will bundle the services regardless of coding conventions will not overturn on appeal.

  3. #3
    Default Rov & e/m
    I am aware of the policy regarding well and sick on the same day but i was specifically told if there was no complaint stated and an issue was incidently found during the pe then you couldnt charge for it. Has anyone ever heard this or am i incorrect?

  4. #4
    Default I have never heard of it...
    There are sometimes problems that are asymptomatic or that maybe the patient does not mention and the physician finds anyway. I defer back to the theory of "additional work". If the MD says, "hey, I found..." and doesn't do work-up or significant additional examination or treat the incidental finding then I'd report the PE only. If, however, the physician finds something and does do any of the above, then that is outside of the routine PE and requires additional MDM hence should be separately reported whether or not the patient complained. If anyone has an official statement contradicting this theory, I'd love to see it because I'm not aware of anything that does.

    Quote Originally Posted by HBULLOCK View Post
    I am aware of the policy regarding well and sick on the same day but i was specifically told if there was no complaint stated and an issue was incidently found during the pe then you couldnt charge for it. Has anyone ever heard this or am i incorrect?

  5. Default I agree with Belinda
    The complaint does not have to be mentioned in the HPI, if it is found (and of course documented) during the PE and if the problem " significant enough to require additional work, then appropriate office visit should also be reported."

  6. #6
    Kansas City, MO
    Well if there is no HPI, now do you get a level of care?

    Key phrase is "significant amount of extra work" to justify the extra E/M.

    Now as for the issue of the problem being found vs. complained about...I dont think that matters if the work was done. BUT you should have your three key components documented for your E/M code, above and beyond what was documented for the "problem".
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  7. #7
    Milwaukee WI
    Default Don't need history for established
    If it's an established patient you won't need a history for the problem focused exam ... just the "complaint" (which in this example is discovered by the physician), the exam and MDM

    F Tessa Bartels, CPC, CEMC

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