# New to Auditing/Preventative E/M question



## AmyLitterell (May 27, 2010)

Hi everyone..  I'm new to auditing and am currently working on an audit for a Family Practice.  In the charts I'm working on, I'm coming across preventative medicine services.  My question is:  Are there seperate guidelines to audit the preventative E/M codes?  Where can I find them?  Not having much luck on the AAPC site or Google.  

Thank you!!


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## kamikidd (Jun 5, 2010)

*Auditing preventive medicine*

There are no separate guidelines that encompass these codes (99381-99397).  When auditing these services I review the chart by the definition as described by CPT.

_"Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures"_ (AMA CPT 2010)

I make sure an age/gender appropriate history and exam are conducted and documented.  If you don't have a clinical background, good communication with your clinical staff can help you develop paramenters for age/gender appropriate H&P for auditing. 

The second part is auditing the record for the documentation of the counseling and risk factor reduction.  For example, if it is a teenager are they discussing birth controol and seat-belt habit?  For a middle aged woman it may be a discussion about monthly self breast exams.  

Hope this helps!

Helen Avery, CPC, CPC-I, CHC


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