Find-A-Code Focus Newsletter

Preventive Medical Services

By NAMAS - Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA
November 18, 2016
The guidelines for PMS (Preventive Medicine Services), like those of regular E&M services are gray and leave many puzzling questions to the auditor regarding what is exactly is REQUIRED according to guidelines. In this tip, I will try to address the areas of documentation and provide a relatively concise statement of work consideration for each component. However, it must be stated that every organization providing PMS services should have a definitive policy for the providers to abide by through their documentation and encounter with the patient as well as the auditor to refer to when auditing the encounter.
The guidelines indicate that the "comprehensive" indicated in the descriptor of the code does not indicate that "comprehensive" is mandatory... however, before you think "whew!"... let's consider the components and what truly is "appropriate," remembering that the guidelines according to AMA CPT state we must require an "...age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor education..."
So, let's start at the top with the history. Through the history of any patient encounter we would hope to be driving the severity of the patient's condition according to the patient through the interview process of the HPI, ROS, and PFSH. Only, these patients don't have a problem, so how do we address the history?
  • The HPI of the encounter typically defines the symptoms the patient is having because of their chief complaint. Since our preventive patient should be asymptomatic, then they would not have such an HPI to document. However, what we would expect the provider to document is the "interval" history of the patient which would define what has happened with the patient since the last time the provider saw the patient with regards to their preventive needs/history or elements that could impact the preventive well-being of the patient. An example might be a patient that presents who indicates that the dermatologist removed a suspicious lesion a month ago and the pathology identified it as cancerous. This is relevant and brings a different scope of complexity to the preventive encounter.
  • The ROS of the encounter should indicate how the patient is being affected systemically by their chief complaint. Again, the preventive wellness patient would be asymptomatic so how then should the ROS be addressed? We would expect that the provider would document a ROS that is related to the preventive wellbeing of the patient. Therefore, we would be reviewing the ROS to identify if there are any organ systems that have problematic areas or concern that may require a plan of action from a preventive wellness perspective.  Is there a requirement of how much ROS must be included? Well it is age/gender appropriate so how much would that be? That would be driven by the provider of care's clinical discretion as the requirements within PMS guidelines are gray on the ROS with no definitions. I might suggest that a provider include a complete ROS, but would I dock a note without a complete ROS- not as long as I had enough to validate a preventive ROS was done. An example of a valid ROS statement, using the referenced example in the HPI of new cancerous development, Skin: As noted in HPI new cancerous site of the left forearm, but no other skin related issues/concerns.
  • The PFSH of the encounter within a preventive service should review the patient's PFSH as it relates to what do we need to consider about your history when thinking of your preventive wellness needs? That being said, yes we would count anything documented as PFSH that meets the criteria, but ultimately, this would be the function of the PFSH in the preventive encounter. An example of a PFSH might be, Family: Father recently evaluated for elevated PSA   Past: Diabetes x 10 years well-controlled   Social: Still smoking, has been for 25+ years
Moving to the exam of the PMS visit, remember the guidance we have.... Age/gender appropriate exam...I would like to suggest you think of the exam this way.... How little is enough? What I mean is- a preventive wellness exam requires an age/gender appropriate exam-how much does the doctor or the NPP think is enough based on that patients history and well-being? Most commonly, we would hope to have a complete examination, but again with guidelines so gray it would be very difficult to hold a provider to such a requirement. I do tend to ask providers who do less than a complete exam, if a carrier, an attorney, or worse yet a judge asked you why you did less than a comprehensive exam on that patient- what would be the answer? Oftentimes, there is no valid answer and documentation of the examination changes moving forward.
Last, we turn to the plan of care. The plan of care should be relevant to preventive wellness needs of the patient, providing an assessment of the patient's overall wellness picture and ordering or indicating what additionally is needed from a preventive plan for that patient.

If you are a provider and your services are being reviewed by an auditor (internal, external, or carrier), or if you are an auditor being audited through a QA process, remember you have the right to substantiate your findings based on your interpretation of the guidelines when there is absence of further policy, regulation, or guideline. Be sure to review commercial carrier guidelines to identify any specifics they may deem as required for reimbursement, but the moral of the story really is this: Preventive Medicine Services seem to have the most ambiguity of any of our E&M services.

This Week's Audit Tip Written  By: 
Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA 
Shannon is a Partner in our parent organization, DocotorsManagement, LLC and is also the President/Founder of NAMAS


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