maine4me
Guru
I am auditing a record from a visit which the patient was scheduled for a preventive exam. This is noted in the cheif complaint, however the balance of the HPI is related to the patient's continued shoulder/neck pain, and how previous injections helped with this pain. There is a complete PFSH, however the review of symptoms is limited at best. The exam covers all systems, however most findings are just noted as normal. There is no documented counseling regarding preventive measures to be taken for the patient's overall health. The assessment and plan are specific to the patient's joint pain, and as part of the plan another injection was given. This was billed as 99396-25, 20610, J1030, 90471, 90715. The immunization is not documented at all, so should not have been billed. My confusion is that this visit seems more like a problem based E/M and not a preventive exam. Any thoughts?