CPT guidelines only tell us that a preventive visit includes "an age and gender appropriate history, examination, counseling/anticipatory guidance / risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures."
The best want to comply with the required history is to have the patient complete a questionaire in the waiting room before being seen, allowing the physician to then review it with the patient ... "Oh, I see you've had problem with constipation...."
Hope that helps.
F Tessa Bartels, CPC, CEMC
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