Wiki Preventative Exam and Office visit sameday

[Twright]

Please help:

I have providers billing for Preventatave exam and office visits on the same day, when the only thing additionally being done is: review of labs, labs ordered for future, counseled on dietary and lifestyle changes. Would the review of labs and couseling be considered a adddtional visit...?

Thanks
Teri W

 

[mitchellde]

this is all part of the preventive encounter, counseling on diet and lifestyle are preventive measures. To bill an additional visit there must be a patient complaint for an issue not related to preventive , or the provider discovers a new problem, there must be an additional office note that covers, hx, exam, and MDM that does not contain elements already covered in the preventive.
However for ICD-10 CM if the patient has a separate complaint, the dx codes exclude coding the signs and symptoms in addition, you may do one or the other, not both.

 

[MikeEnos]

I agree that it does sound like part of the routine preventive service. I wouldn't bill it seperately unless there were multiple chronic problems that required significant extra work above and beyond a normal preventive service, or if one or more of the problems was worsening or uncontrolled, requiring additional workup.

In terms of how to document that, you do not need an additional office note, it can be part of the note for the preventive service. There should be some history regarding the problem(s) and the additional workup should be described in the assessment and plan. There's no rule that says you can't put history in the assessment and plan, but the 'best practice' is to clearly identify it near the beginning of the note (the subjective portion.)