documentation requirements for preventive visit

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documentation requirements for preventive visit

Postby lizzie3k » Wed May 03, 2017 11:51 am

I have only audited preventive exams (annual exam visits) based on age, gender and counseling, not the components. However, per the description in CPT book, it states the E/M service includes a comprehensive history and examination appropriate for the patient's age and gender along with counseling and guidance for prevention of risk factors. Therefore, I'm in discussion w/another auditor that is saying since the provider did not document any family history (he did document past & social) that it does not warrant a preventive and she changed the level to E/M problem visit 99201-99215. I still feel it is a preventive as the provider is seeing her for her annual and going over chronic conditions, but no new 'problems' or issues. I would love your take on this....Your suggestions/comments are welcome!

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Re: documentation requirements for preventive visit

Postby brooke.querry » Fri Nov 10, 2017 9:15 pm

Page 9 in the CPT book under Determine the Extent of History, the last paragraph says the preventive history is not problem oriented, requires no chief complaint, but does include a comprehensive ROS, and Comprehensive assessment/history of pertinent risk factors. For the PFSH it says it includes a comprehensive OR INTERVAL past, family, social history. Interval meaning: a period between two events or times, and this does not say that all three are required.
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