Wiki Well visit & e/m help needed

[sluke9]

I need help in determining when to allow an E/M with a well visit. I understand it must be separate identifiable. I have a doc that wants to bill E/M with every well visit if he addresses another issue in the assessment/plan. The HPI will sometimes address 1 item about it, the exam is comprehensive for the well exam, assessment will have the diagnoses and sometimes a prescription is given.
Example: HPI only states asthma with no other information, A/P states asthma with maintenance discussion & rx given.
Would this be enough and if so, what level would you allow?

 

[LLovett]

No, that would not be enough.

Even though you are not required to document the visits separately, adding the 25 indicates that the problem visit is significant and separately identifiable. Which means it can stand on its own and is not inclusive to the other service. Generally if it is questionable, I will physically go thru a hard copy of the note and mark out everything related to the well care. Then you can see whats left and if there is enough to support a problem E/M.

In the case of the well and problem visit, since the exam is not defined by the well care codes you really can't use those elements towards your problem visit. Leaving you with history and medical decision making as your 2 key components to level with. As with any problem E/M, you need a chief complaint which then should drive the history. A statement of a chronic condition with no chief complaint or any HPI elements or status would not support a history level. So in this case all you have is the MDM, which is not enough to support an E/M code for the problem portion.

Hope this helps,

Laura, CPC, CPMA, CPC-I, CEMC