Wiki confused about well visits/physicals

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gd100

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Hi everyone. I'm a bit confused regarding well visits/physicals. I just started to code for them. A patient came in for his yearly well visit/physical and he was billed for a f/u - 99213. He stated what was going on with him, but there is no indication that he would require tests or see a specialist. I'm thinking it would be a 99395? Any help is appreciated.
 
can you remove identifying factors and post the chart note? Preventives are not to be billed as E/M 9921X codes. (If the documentation does not support a prev exam then the 9921X code is appropriate)... but hard to give you a straight answer without seeing the documentation.
Or if easier simply check out articles on the aafp.org site - do a search for preventives and you'll find the requirements needed. Lots of good info out there.
 
I forgot to mention that here on this site, if you have access to the AAPC Coder area, you can type in serach terms or CPT/HCPCS codes and you'll be able to view "lay terms" on codes, etc... very helpful as well.
 
It would be incorrect to assign a regular offiice visit such as what you describe if the sole purpose was for a routine physical/wellness exam. If other signficant issues were addressed (key word = significant), then depending on documentation an office visit could be assigned with modifier 25 in additional to the well visit.

And yes the aafp.org site is a very helpful resource, as Teresa advised.
 
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