Wiki Preventive visit and E/M?

[pvang]

Hi-

If a patient goes in for an annual exam...and then brings up a concern about vaginal discharge>>>which lead the physician to perform a series of test...would this still be billed as a preventive visit? Or should it have been billed with both a preventive visit and a separate E/M visit? I'm trying to determine whether this visit would even be considered a preventive visit anymore since the patient brought up a concern.
Thoughts?

Thanks-
Pa Tang

 

[aarnold13]

This is a tough one and it happens in our facility all the time. According to the CPT book, you could charge the physical code for the physical part and then an E/M for the vaginal discharge with a 25 modifier. In our office, however, we go back to what the chief complaint is, which in this case was for a female yearly physical. If the office notes talk more about the physical, I personally would code the visit with the physical code having V72.31 as primary and 616.10 as secondary. Then use the 616.10(or whatever your dr wants to use) for the tests that were run for the discharge.
Just my opinion though

 

[pvang]

I just wonder...sometimes is it possible for physicians to perform annual exams without the patient knowing that they are there for a physical? In this case that I'm reviewing, the patient states that the visit was for the vaginal discharge problem she has been having not for an annual. In the medical records it states that patient is "here for her annual exam".

So how would you code a visit like this then?
Thanks!