Bchase11
Contributor
I know you can bill a sick visit along with a well visit but are there rules concerning the office visit LEVEL and the exam? I feel the physicians might be under coding but perhaps there's a reason? Any advice?
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Wiki Sick visit with in a well vist
- Thread starter Bchase11
- Start date
To bill a sick visit at the same time that patient is having a physical or well child check the sick services need to be able to "stand on their own."
This means that the documentation of the illness would be pulled out separately = you would look for documentation in the history, exam, and MDM that relates only to the illness/injury and code with this information only. Using this information you would level the claim as normal. Same rules as normal apply to a new and established patient. For new you need 3 out of 3 and for established 2 out of 3.
Example would be a patient that comes in for a well child check and during the visit the patient complains of ear pain. During the exam the physician finds an ear infection and prescribes an antibiotic. You would use any information related to the ear pain/infection to the level the claim.
This means that the documentation of the illness would be pulled out separately = you would look for documentation in the history, exam, and MDM that relates only to the illness/injury and code with this information only. Using this information you would level the claim as normal. Same rules as normal apply to a new and established patient. For new you need 3 out of 3 and for established 2 out of 3.
Example would be a patient that comes in for a well child check and during the visit the patient complains of ear pain. During the exam the physician finds an ear infection and prescribes an antibiotic. You would use any information related to the ear pain/infection to the level the claim.
Bchase11
Contributor
so using the term "See well visit for additional Findings" is ok for History, but not the exam itself, correct?
I am not sure of what you are referencing when you say "see well visit for additional findings" Is the provider completing two separate documentations for the visit? One for sick and one for well?
Bchase11
Contributor
Yes, the software does it. Isn't that strange??? I just came on in June and I told them they could absolutely not do this and the physicians and manager said they were told differently?
Definitely strange. If they are documenting two separate records then they need to document fully on each one and should not reference the well visit for additional findings. For a clean record and audit all details related to the sick visit need to be listed on one and the details of the well visit on the other.
Bchase11
Contributor
Well I thank you very much for your time and your help!