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medical decision making for Preventative Exam

  1. #1
    Default medical decision making for Preventative Exam
    Medical Coding Books
    I have a cc that says physicial. the physical if fairly extensive labs were extensive but in the medical decision making he does not list the preventative diagnosis. Does the preventative diagnosis have to be there. he reviewed the patients existing disease process and provided refills.
    All input would be appreciated.
    Debbie Potts England
    Lyles, TN 37098

  2. #2
    Milwaukee WI
    Default Review CPT Guidelines
    I'm not sure I understand your question. Per CPT 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."

    There is no specific requirement for MDM.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    first thanks for your reply. I understand no mdm is required. What I am trying to ask is if the physician must list the preventive examination as his diagnosis or if it is ok for me to attach it as that was the chief complaint, ect.
    Debbie Potts England
    Lyles, TN 37098

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