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Preventive Visit Documentation Requirements

  1. #1
    Default Preventive Visit Documentation Requirements
    Medical Coding Books
    When billing a preventive E/M code, what are the documentation requirements for the History and Exam in order to bill accordingly? We have a number of cases with different amounts of documentation with patients coming in for health maintenance, thanks!

  2. #2
    Salt Lake North
    I code for a doc that does routine exams. He also likes to have his patients come in once a year for a complete physical (not a routine, but complete physical) in order to make sure that chronic conditions are being controlled and to find any new medical conditions. I asked him what the difference was between his annual exam verses his routine exam and there was none. Per CPT the exam just has to be age appropriate and allows the physician to do what they deem medically necessary. What he does when a patient comes in for a "Routine" exam, is state that as the CC.

    If your going to bill for a "Preventative" exam, the physician needs to state that in the medical record for the CC. He can't say the patient is there for for their DM, HTN and COPD and then bill a routine exam. That would not make sense.

    I hope this helps.

  3. #3
    Thanks E/M coder. We follow the same guidelines regarding it having to be once a year and the DR needing to document the correct CC in the Hx.

    I was more concerned with how many elements need to be documented in the Exam and the History's ROS. My colleague mentioned that both need to be comprehensive but I cannot find anything official regarding this.


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