What we do is to rely on the Subjective documentation (HPI) and the Assessment/Plan (MDM) to determine the carve-out for the additional office visit on the same day as the cpx. System review must pertain to the complaints in the HPI. We expect that for each HPI, there is a diagnosis an a plan. (we explain to our providers, "Problem, Status, Treatment". ) If PFSH is considered, it can be related only to the HPI problems. The examination is never considered in the calculation of the E&M, nor is any discussion/workup in regards to preventive care. We also insist on "significant additional work", so the usual followup of chronic conditions is rarely considered, (in our facility anyway), part of the preventive visit. Labs/rad/med tests ordered should be related to the 'sick' diagnosis, and not for routine purposes. The same goes for medications..they must be related to the HPI complaints. We look primarily for chronic condition(s) with severe exacerbations, multiple med changes, acute problems or new problems found upon exam, that warrant significant additional work.
Payers vary on payment for this practice. CMS requires that we reduce the amount of the Pe by the amount of the OV. Some commercial payers charge two copays, which makes patients cranky. Others bundle it in, and some apply a deductible/co-insurance that is patient responsibilty. Check your payer guidelines to determine whether or not the balance is patient responsibilty before you balance bill in error.
We bill, for example, 99395, 99213-25. We never bill the OV based on time, because there is no time component for the CPX from which to carve it out.
This is our process, which we've tweaked over the years as we've gotten feedback from payers and external auditors. Hope it helps. Pam
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