Wiki E/M vs Preventive Visit

[LEE ANN]

Patient states was only see for annual physical exam provider billed e/m with diagnosis. The CC & HPI both indicate patient was being seen for annual routine exam and the ROS and Exam portion also support this. Is it reasonable to code a routine physical Z00.00 even though the providers assessment is xxx - which is only mentioned in the patient's active conditions and not addressed anywhere else? Or would you query the provider to have amended assessment done adding the routine exam dx?

 

[1formissy]

On an audit perspective, because I have seen this before time and time again, the only way a provider can report an E/M in conjunction with a Wellness or Preventive Exam, is if that E/M is significantly separate and identifiable. If the patient has presenting problems that are addressed and a plan of care is documented, than an E/M would be supported separately. However, just simply saying Patient is here for wellness exam, or physical, is not sufficient in reporting a separate E/M.