Patients who come into the office for a physical or wellness visit often have a problem they want to discuss, or chronic conditions that need to be assessed and managed. Whether the patient is receiving a preventive medicine service or a Medicare wellness visit, the decision is the same. Report both services when the practitioner assesses and manages an acute or chronic problem and documents the service. Select the level of service based on the documentation: what level would have been billed if it were a stand alone service.
When do these problem oriented discussions rise to the level of an additional problem oriented office visit?
This brief video will guide you about when to add on an additional problem oriented visit.
CodingIntel members, you can watch our webinar Preventive medicine and Medicare wellness visits with an E/M for an in-depth discussion of this topic.
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