Wiki Scheduled vs. Documented

[kathymoon]

Need opinions: One person in our office says that if a patient states in his/her words that they are here for a "Complete Physical" then he/she must be seen and billed for a 9938x-9939x (Comprehensive Preventive Visits).
The second person in our office states, if the provider performs a comprehensive exam and deals with multiple chronic conditions, medications, lab review a diagnostic visit can be billed (99201-99215).

So what do the coders think. Who is right #1 or #2.

 

[rhh03]

I would think it would go by what the physician documented. B/c if there is a request for medical records you want everything to line up properly. Otherwise, your office could owe money to the insurance company


Renetta Houston-Hollingsworth, CPC

 

[mitchellde]

Just because the chronic conditions were managed with prescription refills and labs, does not mean it is not a preventive encounter. An expectation of the preventive encountwr is that the patient will receive there prescription refills. So if the patient expressed no symptomatic issues then it is a preventive encountwr.

 

[GJackson]

Always go with the providers documentation.