Wiki Wellness visit documentation

[adh85]

Hello,

I am wondering if anyone can point me in the direction of documentation guidelines for physicals. Is there a set # of exam points required? Does a provider HAVE to do labs and counseling?

For example pt comes in Dr. Does a breast and pelvic exam only...labs arent done at this time. Is this still a 993xx?

Or a pt comes in and Dr. does an exam on 8 systems but no labs or counseling are done...Is this a 993xx?

Any help would be appriciated as Im on the fence about this quite often.

Thanks-
ADH, CPC

 

[teresabug]

Hi,
I follow the recommendations that I found here on the AAPC Coder... (it is a separate tool that you have to pay for-fortunately my employer pays the yearly fee)... Preventives per AAPC require a "comprehensive" ROS (not the same as the 1997 e/m guidelines), a complete PFSH and a "thorough assessment of risk factors based on age and gender". If your provider only did a pap/pelvic, your dx code would be V72.31. If a full exam was done use V70.0 for adults. For children use either V20.0 or V20.2... my providers counsel on weight management, smoking cessation, caffeine use, alcohol, reviewed meds, etc... fall risks; they note family and school info on children (carbon monoxide detectors, any pets in the home, any allergies to the pets, living situation i.e. divorced/married parents)... hope this helps. I wuold think yearly labs would be an automatic for a provider to order to check cholesterol, etc.... but I don't think its a "requirement".

 

[arkassabaum]

Wellness exam documentation

FOR THE EXAM ITSELF, ARE THE PROVIDERS REQUIRED TO DO A CERTAIN AMOUNT? IVE SEEN PROVIDERS DO CONSTITUTIONAL, RESP, CARDIAC, ABDOMEN, SKIN AND NECK. IF IT WERE PROBLEM VISIT IT WOULD BE AN EXPANDED EXAM WITH 8 ELEMENTS. ARE PREVENTATIVES SUPPOSE TO BE HEAD TO TOE OR CAN IT BE WHATEVER THE PROVIDERS CHOOSES?? (NON MEDICARE, COMMERCIAL ONLY INSTANCE) THERE IS SOME CONFUSION GOING ON AND I WOULD LIKE TO SETTLE IT

 

[Radcoder86]

This is something I'm curious about too. I just started working for a clinic where a couple of the doctors don't even write up a chart note for Wellness exams. They have paperwork that they have the patient fill out that asks about ROS and PFSH and some other things and they just make little notes on the paperwork, but that's it. It's very confusing to review it and I'm curious if that would hold up in an audit.