# Annual Gyn + Office visit



## anuja.devasthali (Sep 7, 2009)

Our Family practise provider has performed Annual gyn exam for patient. Patinet has also complaint of rash. Patinet is an established patient.
Do we need to add office visit (99212 / 99211) with preventive care CPT code or only preventive care CPT code is sufficient ?

Anuja, CPC-A.


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## mitchellde (Sep 7, 2009)

you may code for an office encounter if the physician dictates this as a separate office note to be evaluated as a separate encounter.  None of the elements of the preventive can be duplicated on the office visit so it will be probably a level 2.  Then you put the 25 modifier to the visit level.  Without 2 separate notes then it is either a preventive encounter or an office visit level.


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## drsunitha (Sep 7, 2009)

*Drsunitha*

I agree with debra as she said it cannot be given until unless your physician dictated it as separate encounter on the same day .If he said so give 25 to office visit only.


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## drsunitha (Sep 7, 2009)

*Drsunitha*

ANJALI

Actually this guideline given by ALLISON helped me a lot.Hope this works for you also.

Here are the guidelines used to determine when to bill a Preventive & E/M on the same date of service.

It is not uncommon to discover problems during the course of an encounter for preventive medicine. The complexity of the Medical Decision Making (MDM) for the problem or pre-exsisting condition determines if an E/M should be billed in addition to the preventive CPT code.

Significant Problem:
If the problem is significant enough that it requires the performance of key components then the service may be reported in addition to the preventive code. Example: 99213 or 99214

Insignificant Problem:
If the problem or pre-exisiting condition does not warrant significant work or effort it would not be appropriate to report a seperate service. 
Example: 99211 or 99212.

In addition a E/M service requires a Chief Compliant, so if there is not a documented cheif complaint the E/M service would not be supported. The refilling of mediciations for established diagnosis would not support billing an E/M service in addition to the preventive service.

Seperate documentation is not required but strongly recomended. Each CPT billed should have it's own documentation to support billing the service.

Hopefully this answers your question. Have a great day.

Allison L. Wickham, CPC, CEMC


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## mitchellde (Sep 8, 2009)

I wish I had copied it but for some reason I did not.  However several months ago on the AMA website they discussed the issue of a preventive and E&M on the same day, and in that article they stated that the office visit should not be higher than a level 2.  The rationale they gave which makes a lot of sense was that, if your patient is so ill or has so severe a problem that the physician must expend the intensity of a level 3 or higher visit to address the concer, then the patient is too ill to be subjected to an annual visit, and if done the annual will not provide the baseline for the patient that the physician is seeking.  
I agree with this logic from the AMA.   Just thought I would throw this in there.


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## LLovett (Sep 8, 2009)

You don't need a separate note but the information does have to stand on its own and can not be used for both visits.

I understand where the AMA is coming from to an extent but think about it in terms of an established patient with a bladder infection. That is an easy 99214, if they document it, and wouldn't stop them from doing a yearly physical.

Just my opinion,

Laura, CPC, CEMC


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## kendrahawkins (Feb 21, 2019)

drsunitha said:


> ANJALI
> 
> Actually this guideline given by ALLISON helped me a lot.Hope this works for you also.
> 
> ...



Hi Allison, do you have a reference link to the information you provided?
Thank you.


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