99215 w/ 99395
Hi All,
to code preventive medicine, we need to have CHIEF COMPLAINT for preventive medicine. e.g. pt here for ANNUAL PHYSICAL EXAM, SPORT MEDICINE, ESTABLISHING CARE, ROUTINE EXAM, COMPLETE EXAM, GENERAL EXAM, WELL WOMAN EXAM, WELL CHILD EXAM, etc.
so as to qualify for preventive medicine chart should have CHIEF COMPLAINT, PFSH, comprehensive ROS and PE and COUNSELING. if chart having all these factors then we can code for preventive medicine.
if any of these factors missing, then chart do not qualify preventive medicine. and we should code for other problems if any.
if pt is coming for both i.e. say ANNUAL PHYSICIAL EXAM along with other complaints and chart qualifies for preventive medicine too. then we can code PREVENTIVE along with Other problems too. but in this case we should consider only related bullets/systems for problems.
so in such cases level may not go to 99215, as we will consider only related bullets/systems.
Hope this is helpful.
Thanks
Sujit More, CPC