Medicare Compliance & Reimbursement - 2017 Issue 12
You Be the Coder: Lesson Learned: Reporting Preventive Service With Problem-Oriented E/M
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Article Overview
This coding Q&A discusses a preventive medicine visit for an established adult patient and the separate evaluation of an additional problem addressed during the same encounter. It is aimed at coders and billing staff who work with office/outpatient E/M reporting, preventive medicine services, and diagnosis coding linkage. The article covers the general documentation and diagnosis-support concepts involved in reporting both services, along with the related CPT and ICD-10-CM identifiers mentioned in the example.
Why This Topic Matters
Correctly distinguishing a preventive visit from a separately identifiable problem-oriented E/M service can affect claim acceptance and code reporting accuracy. The article also highlights the importance of matching each service with appropriate diagnosis codes and supporting documentation.
Article Sections
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Question
Presents a brief encounter scenario involving a preventive visit and a separate problem addressed during the same appointment.
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Answer
Explains the general coding approach discussed in the article and references the related E/M and diagnosis coding concepts.
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Documentation and Diagnosis Coding Reminder
Summarizes the article’s discussion of supporting both services with appropriate diagnosis coding and documentation.
What You Will Learn
- How a preventive medicine visit may relate to an additional office/outpatient E/M service
- How documentation and diagnosis linkage are discussed in a same-day preventive and problem-oriented encounter
- Which coding sets are referenced in the example scenario for office/outpatient E/M, preventive medicine, and diagnosis coding
- How modifier use is presented in the context of a separately identifiable E/M service
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Physician office staff
Codes Discussed
Modifiers Discussed
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