Many providers find coding Preventive rehabilitation (Health Assessments) and Office Visits very confusing. In fact, many feel that it is not worth it. It seems easy enough, an established 34-year-old male sick person comes in for their every year condition appraisal and also have other conditions like Htn, Diabetes Mellitus and Hyperthyroidism that were addressed. Why shouldn't I be able to use a Preventive rehabilitation code (99395) with at least a low-level established sick person visit (99213) and modifier 25?
Well your partially right. See, a condition appraisal is.... Well exactly that. It is an appraisal of your patients ample health. The extent and focus of the services will largely depend on the age of the patient. When a victualer conducts a condition appraisal it is incredible that the victualer will chart a ample age and gender thorough history /exam. At this time I would like to elucidate the term "comprehensive". As you may be aware, Office visits have ample history and exams too. However, ample in a condition appraisal (99381-99397) is not synonymous with ample exam in an office visit (99201-99215). Meaning, the Nature of the presenting question dictates the elements in your history, exam and medical decision-making for office visits. In other words, if a sick person presents for a splinter on a finger, a ample history and exam should not have to be attained to gain the information, and the medical decision-making should only show the principal rehabilitation for removing a splinter (Always remember medical necessity). Other foremost facts about condition appraisal are anticipatory guidance, risk factor discount interventions or counseling, and management of insignificant problems.
Chief Smoker
So, what should you do when you have a sick person with an acute condition (chest pain) and/or chronic condition (Htn) presenting for an every year condition Assessment?
You should take a ample history, ample exam and order allowable laboratory/diagnostic procedure. Now lets take a look at the acute and/or chronic conditions. Providers should ask themselves if the condition is requiring work up that is over and beyond their usual. Remember, documentation guidelines are not the same for condition assessment. In other words, condition Assessments does not rely on a chief complaint or a history of presenting illness. Also, a condition appraisal is not question oriented. condition Assessments rely on a ample Ros (Review of Systems), a ample Pfsh and a ample appraisal of risk factors. Since you already documented a ample history and exam, this would be determined overlapping. Therefore, the E/M reported for the question visit (99201-99215) should be based on further work performed by the victualer in determining the best procedure of activity in treating this problem.
Ask yourself, can this condition stand on its own? Is this condition principal sufficient to have its own encounter?
When using an office visit code (99201-99215) with a condition appraisal (99381-99397), a modifier 25 should be used to show the separately identifiable assistance that was performed within the every year exam.
Modifier point: Modifier 25 is used to show a significant, separately identifiable appraisal and management, assistance by the same physician on the same day of the procedure or other service. This modifier can only be appended with an E/M code.
Preventive rehabilitation Example:
34-year-old male comes in for routine every year visit. sick person is also noted to have Htn. Htn is garage w/ diet and medication. sick person has no complaints. A ample history and exam is taken. victualer orders labs and tells sick person to continue with current medication.
S: sick person here for every year follow-up. sick person has Htn. No complaints.
No f/c, chest pain, dyspnea, blurry vision, sore throat, n/v, allergies, lymph abnormalities, thyroid problems, urinary incontinence,
Medical hx: Htn
Family hx: father has Dm
Social: non smoker, public drinker, married
O: 130/70, 96.7
Heent: anicteric sclera, Ent: normal
Cardio: normal Rrr
Lungs: Clear to Auscultation
Ext: good Rom, no abrasion, no edema, skin tight
Neck: no lad
Neuro: A&O x3,
Gi: soft nontender, normal Bs
Gu: Normal
Anticipatory advice discussed about rehearsal and medication. sick person indicates understanding
Assessment: condition checkup,Htn
Plan: Continue meds as ordered.
Dx(s): V70.0, 401.9
Cpt: 99395
Preventive rehabilitation with office visit example:
52-year-old established sick person presents for an every year exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a effective cough over the past week and that the pain is worse on deep inspiration. No f/c, dyspnea on exertion, n/v. Remember, you are going to document further history to reserve the exacerbated condition. Your exam is going to still ample for the condition appraisal with extra documentation of the affected area(s) (Cardiovascular and Respiratory). An Ekg and chest X-ray is ordered and reviewed. Your final prognosis is acute bronchitis and chest pain.
Assessment: condition checkup, Acute Bronchitis, Chest pain
Plan: Medication for Acute Bronchitis is prescribed.
Dx(s): V70.0, 466.0
Cpt: 99397 (Health Assessment)
99213(Problem visit) -25 (Significant, separately identifiable assistance by same victualer on same day)
93000 (Ekg)
71020 (Chest xray, Pa and lateral)
Please note, the above cases are examples only. As with all documentation, providers should all the time report the exact level of assistance by the documented history, exam and medical decision making. To find more examples of using preventive rehabilitation codes with and without office visits, go to your respective medical societies; Aafp, Acog, etc... They are all the time a great resource for information!
health Assessments, Office Visits and Modifier 25, Oh My!