Wiki Preventive Visit and a Sick Visit

[KoBee]

I understand when billing for an additional E/M during an annual preventive visit, it is best practice for our providers to have the discussion with their patients about possible co-pays.

I noticed some providers DO not mention nor document the concern in the chief complaint nor condition in the assessment in plan, but there is an exam documented and/or orders of diagnostic testing or new prescription meds that is not related to the preventive.

Should we not be querying the provider for missing condition? isn't this considered extra work and an abnormality which is not part of the preventive visit to charge or code an additional E/M?

I understand this is a grey area.

 

[kdlberg]

I would query based on the idea that, if I took out everything related to the preventive visit, I would not have a billable chart. There has to be a something to support the medical necessity of the other services. It can be something super basic--"cc: recurring headaches."

If a new problem is discovered during the ROS or exam that the patient didn't bring up, and the provider orders additional testing, they should at least code the symptom(s) that caused them to order the testing. The A&P should explain their reasoning, like "they have this symptom, i'm ordering this to r/o conditions X and Y."