# Requirements for a wellness exam (99396)



## ginawashington (Sep 14, 2012)

Will someone please clairfy the requirements for a wellness visit. I know an appropriate history and exam are required. But, how about the review of systems?? There seems to be some confusion amongst a group of coders I work with.


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## hewitt (Sep 14, 2012)

Preventive medicine visits are not sick visits, but a comprehensive (history & exam) evaluation/reevaluation and management of an individual including an age and gender appropriate history. What is appropriate varies per the age of the patient.

..."the types of preventive services provided in these visits vary and are directly related to the age of the patient. For example, preventive medicine E/M services for a 28-year-old woman may include performing a pelvic examination, obtaining a Pap smear, breast examination, and blood pressure check. Counseling may be provided regarding diet and exercise, substance use, and sexual activity. A preventive medicine E/M service for a 13-year-old girl who is an established patient may include, a scoliosis screen, assessment of growth, development, and behavior, and review of immunizations. Anticipatory guidance may be provided to the adolescent regarding good health habits and self-care, including avoidance of drugs, alcohol, and tobacco, sexual safety, and other peer-pressure issues such as, how to reduce the health risks associated with sexual activity and the importance of educational activities and social interaction." However, the parenthetical paragraph at the beginning of these CPTs give a better explaination of what could be evaluated.


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