# Annual Wellness with E&M documentation



## juneh (Mar 5, 2019)

*Good morning, we need help. Our doc's are billing and E&M with most Annual wellnes visits. I am posting an example visit note, I do not see enough treatment or discussion for an actual E&M visit. He billed;
99396 and 99214,25 , 
Here is the visit note. Complete;*



Chief Complaint
ANNUAL EXAM
Patient's Care Team
Vitals
BP:	140/78 sitting R arm 02/18/2019 10:30 am
138/78 sitting L arm 02/18/2019 10:31 am	Pulse:	88 bpm regular02/18/2019 10:28 am	Wt:	150 lbs With clothes 02/18/2019 10:28 am
Ht:	5 ft 6 in 02/18/2019 10:28 am	BMI:	24.2 02/18/2019 10:28 am	O2Sat:	98% Room Air at Rest02/18/2019 10:28 am
Measurements
None recorded.
Allergies
Allergies not reviewed (last reviewed 04/03/2017)

NKDA
Medications
Reviewed Medications

ALPRAZolam 0.25 mg tablet
Take 1 tablet(s) every day by oral route as needed.	02/07/17   filled	PRIME
atorvastatin 10 mg tablet
TAKE 1 TABLET BY MOUTH DAILY	01/11/19   renewed	
cinnamon bark-chromium picolinate-ALA 500 mg-100 mcg-150 mg capsule
Take by oral route.	02/07/17   entered	
Co Q-10 100 mg capsule
Take 1 mg every day by oral route.	04/03/17   entered	
diazePAM 5 mg tablet
Take 1 tablet(s) every day by oral route as needed for 5 days.	08/03/18   prescribed	
Enteric Coated Aspirin 81 mg tablet,delayed release
Take 1 tablet(s) every day by oral route for 90 days.	02/18/19   prescribed	
meclizine 25 mg tablet
Take 1 tablet(s) 3 times a day by oral route as needed for 10 days.	08/03/18   filled	
Ocean Blue Omega-3	09/21/16   entered	-
progesterone micronized (bulk) 100 % powder
Take 50mg progesterone, 0.5 mg of biest 80:20, DHEA 10mg in vaginal cream to be used nightly.	12/14/18   prescribed	, DO
Restasis 0.05 % eye drops in a dropperette
INSTILL 1 DROP INTO AFFECTED EYE(S) BY OPHTHALMIC ROUTE EVERY 12 HOURS	10/12/15   entered	-
Vitamin D3 2,000 unit capsule
Take 1 capsule(s) every day by oral route.	09/21/16   entered	
Vaccines
Reviewed Vaccines

Vaccine Type	Date	Amt.	Route	Site	NDC	Lot #	Mfr.	Exp.
Date	Date
on VIS	VIS
Given	Vaccinator
Diphtheria, Tetanus, Pertussis
Tdap
09/24/18	0.5 mL	Intramuscular	Arm, Left Upper		u5872aa	Sanofi Pasteur	02/06/20	02/24/15	09/24/18	TANYA SOLOMON-GIBBS																																																		
Influenza
influenza, recombinant, quadrIvalent,injectable, preservative free
09/24/18	0.5 mL	Intramuscular	Arm, Right Upper		qfaa1805	Protein Sciences	06/02/19	08/07/15	09/24/18	TANYA SOLOMON-GIBBS																																																		
influenza, injectable, quadrivalent, preservative free
11/20/17	0.5 mL	Intramuscular	Deltoid, Left		ui892ab	Sanofi Pasteur	06/06/18	08/07/15	11/20/17	TANYA SOLOMON-GIBBS																																																		
Some vaccines listed in Documents: #10643964, #10907796, #11877840, #11978595, #12114677, #12618937, #13156615, #13765252, #13829610, #14669904, #14733420 could not be added to this patient's chart. Please review these documents and add these vaccines to the patient's chart manually as needed.
Problems
Reviewed Problems

•	Vitamin D deficiency - Onset: 11/12/2012 - LAST ASSESSED: 18 NOV 2013 10:33AM; TYPE: CHRONIC; LAST EDITED: 18 NOV 2013 10:46AM; STATUS: ACTIVE; LAST REVIEWED DATE: 20131118; PROBLEM CATEGORY: ACTIVE
•	Mixed hyperlipidemia - Onset: 02/18/2019
•	Hyperlipidemia
•	Anxiety state - Onset: 01/10/2014 - LAST ASSESSED: 10 JAN 2014 1:28PM; TYPE: CHRONIC; IDENTIFIED BY: GUNTHER, ELIZABETH; LAST EDITED: 10 JAN 2014 1:29PM; STATUS: ACTIVE; LAST REVIEWED DATE: 20140110; PROBLEM CATEGORY: ACTIVE
•	Anxiety - Onset: 02/18/2019
•	Benzodiazepine dependence - Onset: 02/18/2019
•	Tear film insufficiency - Onset: 04/23/2012 - LAST ASSESSED: 23 APR 2012 1:57PM; TYPE: CHRONIC; IDENTIFIED BY: BERKMAN, ANDREW; LAST EDITED: 23 OCT 2013 12:20AM; STATUS: ACTIVE; LAST REVIEWED DATE: 20131023; PROBLEM CATEGORY: ACTIVE
•	Chronic kidney disease stage 3 - Onset: 02/18/2019
•	Menopausal symptom - Onset: 11/12/2012 - LAST ASSESSED: 09 JUN 2015 10:04AM; TYPE: CHRONIC; IDENTIFIED BY: GUNTHER, ELIZABETH; LAST EDITED: 09 JUN 2015 10:05AM; STATUS: ACTIVE; LAST REVIEWED DATE: 20150609; PROBLEM CATEGORY: ACTIVE
•	Osteoporosis - Onset: 02/18/2019
•	Prediabetes - Onset: 02/18/2019
•	Extremely dense breast composition
•	Elevated blood-pressure reading without diagnosis of hypertension - Onset: 02/18/2019
•	Adult health examination - Onset: 02/18/2019
•	Screening for malignant neoplasm of colon - Onset: 02/18/2019
•	Screening for disorder - Onset: 02/18/2019
•	Body mass index 20-24 - normal - Onset: 02/18/2019
Family History
Discussed Family History

Mother	- Primary malignant neoplasm of lung (onset age: 86) (died age: 86)
Father	- Myocardial infarction (onset age: 40) (died age: 80)
- Dialysis for 2 years
Social History
Discussed Social History
Internal Medicine and Routine Gyn
Are you currently employed?: Y
Live alone or with others?: with others
Able to Care for Self: Y
Hard of hearing or deaf in one or both ears?: N
Legally blind in one or both eyes?: N
Alcohol intake: Occasional
Smoking Status: Never smoker
Non-smoker
Tobacco-years of use: 0
Seat belts used routinely: Y
Performs monthly self-breast exam: Y
Surgical History
Reviewed Surgical History

•	Other
•	Breast Biopsy - 07/23/2012 - MRI guided - negative
•	Appendectomy - 05/12/2002 - Severe rupture with peritonitis/post-operative abscess - Dr. Kearney
•	Breast Biopsy - 07/23/2000 - INCISIONAL BREAST BIOPSY - negative
GYN History
Reviewed GYN History

Obstetric History
Reviewed Obstetric History

Past Medical History
Discussed Past Medical History
High Cholesterol: Y
HPI
62F with PMH HL, CKD3 baseline Cr 1.1, prediabetes, anxiety/bzd dependence.


HL. tolerating meds. no myalgias, chest pain, dyspnea, orthopnea, palps, edema.

CKD3. avoid NSAIDs. urinating normally.

anxiety. bzd dependence. no si/sa/hi/ha, pt understands to call 911 immediately if any of these occur.
ROS
Patient reports no fever, no night sweats, no significant weight gain, no significant weight loss, and no change in appetite. She reports no change in vision, no eye discharge, and no eye discomfort. She reports no difficulty hearing and no ear pain. She reports no frequent nosebleeds, no sinus congestion, and no nasal discharge. She reports no sore throat, no bleeding gums, no dry mouth, no mouth ulcers, no change in sense of smell, and no change in sense of taste. She reports no chest pain, no exertional dyspnea, no orthopnea, no palpitations, and no syncope. She reports no cough, no sputum, no wheezing, no shortness of breath, no hemoptysis, and no pleuritic pain. She reports no dysphagia, no abdominal pain, no nausea, no vomiting, and no change in bowel habits. She reports no incontinence, no dysuria, no hematuria, no frequency, no vaginal bleeding, and no vaginal discharge. She reports no muscle aches, no muscle weakness, no joint pain, no back pain, and no joint swelling. She reports no abnormal mole, no rashes, and no wounds. She reports no weakness, no numbness, no seizures, no tremor, no dizziness, no headaches, no change in vision, no change in consciousness, and no confusion. She reports no depression, no sleep disturbances, no alcohol abuse, no anxiety, no hallucinations, no suicidal thoughts, and no drug abuse. She reports no fatigue, no temperature intolerance, no unusual weight change, no change in hair distribution, and no tremulousness. She reports no swollen glands, no unusual bruising, and no night sweats. She reports no itching, no hives, and no facial swelling.
Physical Exam
Constitutional: General Appearance: well-nourished, well-developed, and well groomed. Level of Distress: NAD.

Head: Head: normocephalic and atraumatic.

Eyes: Lids and Conjunctivae: no discharge or pallor and non-injected. Pupils: PERRL. Corneas: clear. EOM: EOMI. Lens: clear. Sclerae: non-icteric and no injection.

ENMT: Ears: no lesions on external ear, EACs clear, and TMs clear. Nose: no lesions on external nose or nasal discharge and nares patent and nasal passages clear. Lips, Teeth, and Gums: no mouth or lip ulcers. Oropharynx: no erythema or exudates and moist mucous membranes.

Neck: Neck: supple, FROM, trachea midline, and no masses. Thyroid: no enlargement or nodules and non-tender.

Lymphatic System: Lymph Nodes: no cervical LAD or supraclavicular LAD.

Lungs: Respiratory effort: non labored breathing, normal expansion. Auscultation: no wheezing or rales; no rhonchi.

Cardiovascular: Heart Auscultation: no murmurs, rubs, or gallops and RRR; S1S2. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout. Peripheral Edema absent.

Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness, guarding, masses, rebound tenderness, or CVA tenderness and soft, non-distended, and normal inspection. Liver: non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly. Hernia: none palpable.

Musculoskeletal:: Inspection and Palpation no tenderness or swelling. Range Of Motion Evaluation normal movement of all extremities.

Skin: Inspection and palpation: no rash or jaundice and good turgor.

Neurologic: Power/Tone: normal strength and tone. Gait and Station: normal gait and station. Sensation: grossly intact.

Psychiatric: Insight: good judgement and insight. Mental Status: normal mood and affect and active and alert. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal.
Assessment / Plan
1. Adult health examination - Preventative care: discussed/addressed advance directives (health care proxy), vaccinations, dieting, exercise, vision/hearing evaluations, dental examinations, wearing sun screen, seat belts, no texting while driving, medication adherence, appropriate laboratory testing

depression screening: neg

alcohol dependence: neg

smoking cessation: N/A never smoker

lung ca screening: N/A never smoker

crc screening: never had colonoscopy--counselled on importance of test and referred to GI for screening colonoscopy

breast/cervical ca screening: cbe/mammogram, routine gyn care/pap smear with gynecologist, Dr. Cavalleras

BMD: ordered

HCV screening: declined--discussed with pt rba and pt verbalized understanding and acceptance of risks

HIV screening:declined--discussed with pt rba and pt verbalized understanding and acceptance of risks
Z00.01: Encounter for general adult medical examination with abnormal findings

2. Screening for disorder - 
Z13.89: Encounter for screening for other disorder

3. Screening for malignant neoplasm of breast
Z12.31: Encounter for screening mammogram for malignant neoplasm of breast
•	MAMMO, SCREENING, DIGITAL, BILATERAL

4. Screening for malignant neoplasm of colon
Z12.11: Encounter for screening for malignant neoplasm of colon
•	GASTROENTEROLOGY REFERRAL - 
    Schedule Within: provider's discretion

5. Elevated blood-pressure reading without diagnosis of hypertension - -goal <130/80
-elevated today, previously controlled, monitor
R03.0: Elevated blood-pressure reading, without diagnosis of hypertension

6. Mixed hyperlipidemia - -LDL 114
-ASA 81mg, atorvastatin 10mg
E78.2: Mixed hyperlipidemia
•	Enteric Coated Aspirin 81 mg tablet,delayed release - 
Take 1 tablet(s) every day by oral route for 90 days.     Qty: 90 tablet(s)     Refills: 1     Pharmacy: DRUG STORE 04594

7. Chronic kidney disease stage 3 - -CKD3 baseline Cr 1.1
-avoid NSAIDs
-not on ACE/ARB, check AC ratio
N18.3: Chronic kidney disease, stage 3 (moderate)
•	CHRONIC KIDNEY DISEASE: CARE INSTRUCTIONS
•	MICROALBUMIN, RANDOM URINE (W/CREATININE)
•	MEDICINES TO AVOID WITH KIDNEY DISEASE: CARE INSTRUCTIONS

8. Body mass index 20-24 - normal -
•  diet/exercise/weight loss counselling
Z68.24: Body mass index (BMI) 24.0-24.9, adult

9. Prediabetes - -A1C 5.7
-diet/exercise/weight loss counselling
R73.03: Prediabetes

10. Osteoporosis
M81.0: Age-related osteoporosis without current pathological fracture
•	BONE DENSITY
•	CALCIUM, IONIZED
•	PHOSPHATE (AS PHOSPHORUS)
•	PTH, INTACT WITHOUT CALCIUM
•	VITAMIN D,25-OH,TOTAL,IA

11. Anxiety -
•  no si/sa/hi/ha, pt understands to call 911 immediately if any of these occur
F41.9: Anxiety disorder, unspecified

12. Benzodiazepine dependence - -dependent on diazepam 5mg to help control anxiety symptoms
-can discuss more in detail at future visit other options ie SSRI
F13.20: Sedative, hypnotic or anxiolytic dependence, uncomplicated


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## Pathos (Mar 5, 2019)

Hello,

There are many ways you can approach the "Preventive w/ E/M visit" issue, but let's take it one step at a time.

Firstly, consider the reason for the visit. 

1) Did the patient come in for a *regular check-up *with mostly *stable *conditions, perhaps a few modifications/changes needed? Routine labs/radiology for general maintenance. This all leads towards the visit being preventive (or AWV).

2) Did the patient come in for a *new problem* that needs medical attention and management? *New *Rx, referrals, etc. This would lead towards a regular E/M office visit.

3) Did the patient want his/her *annual visit*, but also had a *number of new* problems that he/she wants managed/treated? - Here's the kicker and many coders/providers like to tackle this sometimes differently. Some suggest that you code on what the provider spent greater than 50% of their time on. Some take a hard stance and say, the patient came in for XYZ, so that's what we're going to bill, and have the patient reschedule for the other type of visit.

Personally, if the medical necessity is there, then it's still *CORRECT CODING*. However, as most of us coders know, just because it's correct coding, doesn't mean the visit will get paid (_Consultations, anyone_?). 
Also, another factor is that if a Medicare beneficiary comes in for what they think is 100% covered, and then end up with a $300 bill; they're likely to be very irate. I know I would be. Communication is key here, that the provider *SHOULD *tell the patient of the likely outcome if they are going to deal with the patient's new problem.

Again, this is just my take on this topic and I am sure other coders might disagree, however I have seen both sides of the coin on this (payer and provider).


Hope this is helpful!


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## mitchellde (Mar 5, 2019)

I see a prevent exam here you could argue  with abnormal findings for the elevated BP and the pre-diabetes.  HOWEVER there was no real work expended on these issues, they are only mentioned in passing in the MDM which does not support a separate visit level.  I see no additional level beyond the preventive.


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