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Help with this scenario!!

  1. Default Help with this scenario!!
    Medical Coding Books
    I am auditing a record from a visit which the patient was scheduled for a preventive exam. This is noted in the cheif complaint, however the balance of the HPI is related to the patient's continued shoulder/neck pain, and how previous injections helped with this pain. There is a complete PFSH, however the review of symptoms is limited at best. The exam covers all systems, however most findings are just noted as normal. There is no documented counseling regarding preventive measures to be taken for the patient's overall health. The assessment and plan are specific to the patient's joint pain, and as part of the plan another injection was given. This was billed as 99396-25, 20610, J1030, 90471, 90715. The immunization is not documented at all, so should not have been billed. My confusion is that this visit seems more like a problem based E/M and not a preventive exam. Any thoughts?

  2. #2
    Chesapeake, Virginia
    I agree, this is a problem-focused visit.

    Had there been preventive counseling or anticipatory guidance documented, this could have been both E/M and preventive. The patient may have presented for a preventive exam, but I don't see a preventive visit here.

    I have to admit I am one of those "problem" mothers who waits until the preventive visit to discuss all my concerns about my kids. It's at the provider's discretion whether to only address the problems and reschedule the preventive, or do it all in one visit. Most of the providers I bill for will do both visits at once, to keep the patients happy.

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