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Preventive or New E/M

Nancy Posted Mon 13th of June, 2011 17:26:14 PM

CC-New patient to establish,referral for mammogram.
HPI-Pt is a 62 yr old female. New pt.to establish care. HTN/High chol/patient on Weight Wathcers. Pt having breast pain on the rt side, last mammogram was 2 yrs agao. last labs 6 months ago. pt wants Wellness visit.
Past Medical/Surgical Hx
Reported Hx:
Pregnancy: Gravida 2
Diagnosis HX:
Hypertension
Hyperlipidema
Therapeutic Hx:
Cholecystectomy
Hysterectomy
Social Hx:
Behavioral: Caffeine use 2 cups of coffee daily. Not smoking. A previous hx of smoking quit 6 yrs ago.
Alcohol: Alcohol use socially
Drug Use: Not using drugs
Habits: Good exercise habits
Work: retires
matial: Currently married
Functional: No physical disability
ROS:
Cariovascular: No symptoms
Pulmonary: No symptoms
GI: No symptoms.
Pertinebt positives and negatives as stated in the HPI; otherwise negative in all 14 systems as reviewed with the patient.
Physical Findings:
Vitals
Heneral Appearance:
Oriented to time, place ad person in no acute distress.
Neck:
Suppleness: The nek demonstrated no decrease in suppleness.
Thyroid: The thyroid showed no abnormalities.
Lungs:
Normal breath sounds/voice sounds, no wheezing was heard, no rhonchi were heard, and no rales/crackles were heard.
Cariovascular:
Heart Rate and Rhythm: Heasrt rate and rhythm normal
Heart Sounds: S1 nomral and the S2 was normal
No murmurs were heard.
Edema not present.
Neurological:
Speech was normal
Gait and Stance were normal.
Psych: Affect was normal
Skin: Skin temperature was normal.
Assessment:
Pain in Rt breast-Possible M/S as pt started exercise and diet program.
last mamogram was 2 yrs ago
Normal routine Hx and Physical
Essential Hypertension-last labs was 6 months ago. Ordered. Atenolo/HCTZ 50/25 g q day request 90 days refill
Hyperlipidema-labs orderd Lovastatin 20 mg Q eve. refilled per pt request
Plan:
Mammogram ordered. labs ordered
Dx HTN/High Chol
OK, after all of that my question is; would you code this as a Preventive or New Patient. My provider did both. I don't feel this is correct. Thanks for your help as always.

SuperCoder Answered Mon 13th of June, 2011 21:29:39 PM

You have mentioned that "patient wants Wellness visit".
When can get a yearly wellness exam?:
“After you’ve had Part B for longer than 12 months, you can get a yearly wellness exam to develop or update a prevention plan just for you, based on your current health and risk factors. This exam is covered once every 12 months.”
...
Please check if the above condition is satisfied, then based on your documentation we can code the initial Annual Wellness Visit (G0438) or subsequent Annual Wellness Visit (G0439) as appropriate.

Nancy Posted Tue 14th of June, 2011 11:42:10 AM

The Annual Wellness Visit does not include a Physical Exam. So with that said, do you believe this is a Preventive?

SuperCoder Answered Tue 14th of June, 2011 14:09:17 PM

With the below mentioned points, I assumed (but really not true) Physical Exam may be a part of AWE. On the other hand if the patient had requested for AWE, then the physician should not provide something else without consent of the patient. Let me check guidelines and come out with an answer regarding if physician performs something else, if the patient has come for AWE.

http://www.cms.gov/mlnmattersarticles/downloads/MM7079.pdf

SuperCoder Answered Tue 14th of June, 2011 15:18:30 PM

There are many contradictions in this documentation.
1. Yes, I agree with you that "The Wellness Exam" does not include a “physical exam”, but here the patient has requested for AWE.

2. When the patient comes for a complaint like breast pain the doctor should perform a new E/M, then why has the doctor provided a Comprehensive Physical Exam, that looks like IPPE.

3. The best option I found is that you need to confirm, if the attending has provided Certification of Annual Wellness Exam for this service or not. If yes, then you need to confer AWE codes, still the question remains: why was a need of Comprehensive Physical Exam?

Getting answer from the provider regarding this query would help correct coding.

To be on safer side, we can code a new E/M only since the patient had come with a complaint of breast pain.

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