# Healthcare maintinance



## MsMaddy (Aug 18, 2009)

Can someone tell me, what can we use for healthcare maintinance visit. Usually the pt comes in without any complaint or the pt want to have blood work done. sometimes the pt will have one diagnosis and the doctor will put on dictation " Healtcare maintinance visit" . Can someone tell me what is the best way of coding this. specially when pt has no problems. 

Thanks in Advance!
MsMaddy


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## rachell1976 (Aug 18, 2009)

We bill it with the preventative medicine codes NP 99381-99387 or Existing 99391-99397

with DX v70.0 routine general medical exam (Health checkup)


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## MsMaddy (Aug 18, 2009)

rachell1976 said:


> We bill it with the preventative medicine codes NP 99381-99387 or Existing 99391-99397
> 
> with DX v70.0 routine general medical exam (Health checkup)





Even if the doctor did not do any physical exam, you used prevenative codes and cpx dx? Normaly the doctor fills out the pink or the blue form for cpx visit, thats when we use the prevenative 99391-99397 and dx v70.0. So your saying we can still use 99391-99397 with dx v70.0 if the doctor only does healthcare maintinance as dx even if the pt did not have the complete physical exam. What is the difference between " complete cpx and healthcare maintinence"? 

thanks again

MsMaddy


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## rachell1976 (Aug 18, 2009)

CPT states that preventitive medicine services include "counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventative medical examination."

According to my ISP Module #2  (2007 pg 11.47) it states "preventative medicine codes for new and established patients include a comprehensive history and examination. The comprehensive *history is not problem oriented and does not require a chief complaint or history of present illness*. It does require a complete systems review and comprehensive or interval past, family and social history, including assessment or history of pertinent risk factors based on the patient's age" 

So based on that information exam is required, but is not the same as "comprehensive" in E/M. 

How much of an exam you need? I would like to get feedback from someone else as to what would be required.


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## MsMaddy (Aug 19, 2009)

Well this is the dictation:

PROBLEM:  Health Maintenance visit.

S: The patient si feeling okay.  He still has infrequent headaches, for which he takes Maxalt and Fiorcet with success.  He has tried to keep stress level down, especially in the work place.  

O:  Weight is 199.8 pounds.  Blood pressure is 102/80. Pulse is 70. Temp is 97.5. BMI is 32.  We disucssed health maintenance and patient's healthcare issue.  Heart is regular rhythm. Lungs are clear. HEENT is clear.  Abdomenis soft and nontender.  Neurological exam is grossly within normal limits. 

A: 1. Non-Gyn/health Maintenance visit
    2. Hyperlipidemia.
    3. Headaches
    4. Depression

P  1. set up for colorectal screening colonoscopy and digital rectal exam with 
       prostate exam at that time.
    2. lab, including CBC, BMP, Lipid< chest x-ray, AST, ALT, and PSA.
    3. continue simvastatin and effexor with p.r.n nasacort and xanax.
    4. TDAP update today.

So, would you still use prevenative code 99391-99397 and dx v70.0 With all the rest of diagnosis and tdap immun ? 

Thanks again
MsMaddy


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## rachell1976 (Aug 19, 2009)

There is an exam there. I quickly count 6 bullet points.


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## MsMaddy (Aug 19, 2009)

rachell1976 said:


> there is an exam there. I quickly count 6 bullet points.




ok, thank you.


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## ARCPC9491 (Aug 19, 2009)

I see quality of care issues here. 

There is a difference between your "annual check up on your issues" and a "preventative encounter". This doesn't seem like a preventative encounter to me but rather a problem oriented encounter poorly documented.

The patient has several illnesses, hyperlipidemia, depression and headaches.  Your physician addresses headaches in the HPI, and in the plan, states to continue simvastatin (for hyperlipidemia) and effexor and xanax (for depression) and is also giving nasacort but for what??? No where in this note states a thing about allergies.  

Then --- we get to the colorectal screening. Why does he want to do this? Has the patient reached any risk factors?? (such as age) (even though preventative, the reason should still be documented)

Then --- we get to the TDAP update. Who is giving it? The nurse? The doctor? CPT 90715 is for intramuscular use. So the route administered should be IM. Additionally, for vaccines, there is a lot number, whoever administers should sign along with their credentials. I'm assuming you have a flow sheet for injections?

99214 (Based on detailed exam & MDM of moderate)
90715
90471

Just my thoughts.


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## MsMaddy (Aug 19, 2009)

ARCPC9491 said:


> I see quality of care issues here.
> 
> There is a difference between your "annual check up on your issues" and a "preventative encounter". This doesn't seem like a preventative encounter to me but rather a problem oriented encounter poorly documented.
> 
> ...



Yes we do have a injection sheet that we document.  I do think your right as this being just problem oriented problem rather than prevenative exam. I'm not sure why this is called healtcare maintenance.

Thanks 
MsMaddy


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## ARCPC9491 (Aug 20, 2009)

Providers call things whatever they want ... even if it's not really what it is. Things often get mistitled as well. It is up to us to decipher what the note really is and code it accordingly!


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