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I have a physician who saw a patient for a preventive visit and also charged a 99215 for this patient on the same date of service. He used the same documentation for both visits. Should he have documented each service separately?
Question: I have a physician who saw a patient for a preventive visit and also charged a 99215 for this patient on the same date of service. He used the same documentation for both visits. Yes, the patient had five to six chronic illnesses or conditions. Where can I find documentation that proves the physician must document each visit separately? Also, can he use the same history for both encounters?
Thanks for any help in this situation. I want to be able to show some documentation to this physician besides just telling him that he needs to have separate, identifiable documentation to support each visit.
Answer: You may want to look at this a little differently. There is no overriding authoritative requirement that says the two "aspects" of the combined preventive/medical management visit need to be documented separately.
They really are two different services being provided in the context of one visit. The "problem list" (assuming the problems are being managed that day) is not part of a preventive service, but should appear in the HPI to give the status of those problems if they are chronic, and some detail on them if they are acute or episodic.
The ROS is somewhat shared between the two services, as is the PFSH.
The exam is also largely shared, except that often you will have some narrative findings related to the "problem" organ systems or body areas. This is the norm for these types of visits.
Maybe the most important part is that the in the A/P, the management of the problems is clear (Dx, status, Tx, and RX per problem) and that there is a separate section that outlines all the preventive aspects of the visit - vaccines, diet, mammogram, DEXA, PAP, etc., or whatever is applicable.
So you are correct in that there needs to be clarity that two services were provided and there was some separation there - but not entirely separate - as if it were one service provided in its entirety that was followed by another. They do kind of "unfold" together, and so the documentation will be mingled a bit.
Just make sure the physician says up front - in the CC - "Here for E&M of HTN, CAD, DM, lipids, and gout as well as periodic preventive medicine services" - or something like that!
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at email@example.com or firstname.lastname@example.org.
This article originally appeared in the May 2011 issue of Physicians Practice.