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Established Preventive Visit with Chronic Conditions

  1. Default Established Preventive Visit with Chronic Conditions
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    can someone tell me if I can bill 2 visits if the patient came into the clinic to have a physical and also has chronic conditions such as diabetes (which is worsening), hypertension and hyperlipidemia...the physician documented that the diabetes is worsening and increased the medication and give a little brief documentation on the diabetes but he also documented that the other chronic conditions were "stable and continue current medications" should I code this? should I code this as:

    99386 V70.0
    99213-25 250.02, 401.9, 272.4

  2. #2
    We on occasion bill them both on the same visit, but it only depends on if the established pt visit code is supported by what the provider documented in records.
    Our provider will have 2 different medical record forms to use for the well child checks & the "sick" new/est pt visits.
    If during the well visit there were other things going on, she'll separately note the cc, take the HPI & note the exam & MDM elements so that another E/M code can possibly be supported.

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