don't want to under bill this

What is the optimal way to bill this situation: I have a 40 year old patient come in for annual physical- during teh preventive care visit, I find abdominal pulsations and abnormal previsit fasting sugar. I do the full physical exam, review the abnormals with the patient and order a ultrasound to r/o AAA and repeat FBW. i bill the visit as a v70 and preventive care CPT® but this DOESN'T cover the additional management for the abnormal findings. Should I bill a separate 99213 for the abnormal part of teh e/m encounter or must I have the patient come back to review what will 99% likley be a normal test result.

99213-25

and link to 790.6 and code for AAA

so the answer is yes?

In that situation I should bill a preventive care visit along with a modifier 25 99213 - do I need a separate progress note of can it be incorporated into my EMr annual progress note template with the relavant abnormals.

yes

bill the preventive code with V70.0, the problem with 99213-25. Your HPI and assessment and plan should be clearly separate- they can be in the saeme note but different sections- HPI- PE- needs colonoscopy, mammo UTD, HTN- taking meds, no CP, SOB. A/P- get colon, HTN- cont meds, get labs, EKG