Wiki Preventative Visit

[Ann]

What history components are needed for a preventative visit? We have an internal medicine provider that will document the patients last eye exam and colonoscopy in the ROS. He does not go into immunizations or exercise in the history. Is this needed for a NON Medicare age patient? Your help is greatly appreciated!

 

[FTessaBartels]

CPT Guidelines

CPT guidelines only tell us that a preventive visit includes "an age and gender appropriate history, examination, counseling/anticipatory guidance / risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures."

The best want to comply with the required history is to have the patient complete a questionaire in the waiting room before being seen, allowing the physician to then review it with the patient ... "Oh, I see you've had problem with constipation...."

Hope that helps.

F Tessa Bartels, CPC, CEMC