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Preventative vs established

  1. Question Preventative vs established
    Medical Coding Books

    established visit- documented as a CPX.
    Several established chronic problems listed-- ALL stable. NO chief complaint, but each chronic problem addressed (some documented as followed by another physician). No HPI-- as the problems are mostly current but chronic in terms of years.
    Good ROS (detailed), EPF to Detailed PE. Medical necessity-- "screening blood work" ordered. Occasional pharmacologic management. Generally chronic but stable problems. Is this preventative i.e. 99397 or established i.e. 99214? Opinions please.

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  3. #3
    Loma Linda
    Thumbs up preventive vs established
    Ok so what about Well Women vs Complete Physical ??? pt comes in for her annual pap only G0101 & Q0091 ONLY ?? Complete physical with age appropriate preventive code and G0101 & Q0091??? do you not use E & M code on Well Women Exam??? I don't get paid for it and sometimes don't get paid for the preventive code either... Is there any ruling on how this is done??

  4. #4
    You would use an E/M only if the patient were treated for a separate diagnostic problem at the same time as their well woman or complete physical visit. For example, the physician treats the patient for hypertension as well as doing their well woman visit, you would use the appropriate E/M code along with modifier 25 for separately identified service with the ICD-9 code of 401.1.

    We use the G0101 and Q0091 for Medicare only and use the age appropriate preventive code for all others.

    Hope this helps!
    Teresa Collins, CPC

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  6. #6
    If there is no chief complaint it would be a physical. If you are doing a physical with a pap and breast exam I would use the physical codes plus
    G0101 and Q0091. I would only use an E/M code in addition to the physical codes if you treated the patient for a separately identifiable service. Just stating the chronic illnesses are stable is not enough for the addition charge.

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