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Preventive visit documentation

  1. Default Preventive visit documentation
    Exam Training Packages
    Is this an acceptable documentation to bill for a separate Preventive Visit?
    Chief Complaint(s):
    Pt is here for annual PE as well as for sick visit for eval of reg medical problems ... see HPI .
    HPI:
    Clinic Visit
    Pt c/o burning sensation around his anus & into penis x's past 1 wk ... no d/c ... + burning on urination x's 1 wk as well ... this is a new problem with BM though "I do strain on passing BM" ... no F/S but + c/o chills occasionally x's past 6 months but no wt chages ...
    ASSESMENT:
    1.ROUTINE MEDICAL EXAM
    Flu shot given 10/3/09 ... H1N1 given @ work 12/09 ... PNA given 12/30/09 ... up-to-date with colonoscopy
    2.URINARY PROBLEMS NEC
    Start Bactrim DS Tablet, 800-160 MG, Orally, 6, 1 tab, twice a day, 3 day(s), Refills 0Lab:URINALYSIS, COMPLETE

    PHY.EXAM;ROS COMPLETED

    My question is this,if during the Preventive Visit there's no LAB ORDERED,no COUNSELING provided if it's still qualifies for a Preventive Visit?

    Thanks.

  2. #2
    Location
    Columbia, MO
    Posts
    12,570
    Default
    I see no preventive encounter here.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Thanks a lot Debra,that's what I'm trying to explained to the Providers.

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