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Office Visit and Annual Physical on same day

George Posted Tue 16th of January, 2018 13:42:18 PM
A patient comes in to review lab results with the doctor. During the visit they discover that they are due for their annual visit. Is it appropriate to bill a 99395 (Annual) along with the appropriate E/M code on the same day.
SuperCoder Answered Wed 17th of January, 2018 04:50:37 AM


Please consider the following explaination :

Preventive E/M codes include a comprehensive exam, encompassing management of chronic and/or stable conditions, abnormal findings on review of systems, and diagnosis and treatment of minor conditions. It is rare that a separate E/M code is justified because its components cannot be independently met, however when documentation is provided that supports reporting the separate service and the problem E/M code is billed with modifier -25, separate payment may be considered.

Further query is welcome.

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