We fight our physicians on this all the time, however if the pt comes in for a routine exam, the CPT book states that an E&M code may also be reported if certain guidelines are met:
"If an abnormality is encounter OR a preexisting problem is addressed in the process of performing this preventive medicine evaluation, and the problem or abnormality is significant enough to require additional work to perform the components of a problem-oriented E&M service, then the appropriate office/oupatient code should be reported with a modifier 25."
This is stated in the info preceeding the preventive med codes. The documentation must support this: the physician must state he is seeing the patient routinely, and document in his note that he chose to turn his attention to evaluating a preexisting behavioral problem(in this case with V40.3).
Hope this helps!
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