Wiki Wellness Exam w/EM....dx linkage

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amexnikki23

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Hi! Here is the scenario. I am trying to figure out what codes to place with what service:

Patient comes for a CPE and "wants STD testing" as per chief complaint.

Has 1 chronic condition (hypertriglyceridemia) but states doing well and no complaints.

Provider performs physical exam and also bills a 99213 linking the following dx codes: STD screening, hypertriglyceridemia, as well as 2 ?found on exam? dxs of elevated BP and tobacco use disorder (in which the patient states he does not wish to quit). No prescriptions written, but order STD blood tests.

Would you bill an EM with this CPE? If so, would you link the 1 chronic conditions and 2 "found on exam" conditions (elevated BP and tobacco use disorder)? Or would you just bill the EM with the ?STD screening? and if so, would you lower the EM to a 99212?

Any and all thoughts are greatly appreciated.
 
If the patient is simply requesting STD screening as a part of the wellness I see no actual separate encounter to bill for this. They are still asymptomatic and still here for preventive. Bill only the preventive with the screening lab code. Use the V70 plus the STD screening V code.
 
mitchellde said:
If the patient is simply requesting STD screening as a part of the wellness I see no actual separate encounter to bill for this. They are still asymptomatic and still here for preventive. Bill only the preventive with the screening lab code. Use the V70 plus the STD screening V code.
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I agree with Debra, CPT says that an insignificant problem that is encountered in the process of performing a preventative medicine E/M service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported. I don't believe a chronic stable and an STD test request justifies reporting a separate e/m.
 
thanks! what the tobacco use disorder and the elevated BP, should that be reported secondary and tertiary as dx codes linked to the wellness exam, or not reported on the claim at all?
 
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