What is required documentation for Wellness Exam?

To bill a preventative visit -99381-7, 99391-7- are there any guidelines about how much Hx, ROS, PE has to be documented?

wellness

No, no key components in preventive exams. It is per age guidelines/recommendations. CPT Assistant published their opinion in the early '90s

What is the required documentation for a wellness exam?

CPT describes these as "age and gender" appropriate histories and exams, and says that they do not correspond to the comprehensive history and exam as defined by the Documentation Guidelines.

I believe in one of the CPT Assistants they said that physicians should consult their specialty societies for guidance in what constitutes an age and gender appropriate history, exam, anticipatory guidance, etc.

Does that answer your question?

It answers it

Mark this down in history- no government requirements- we actually get to do what we think is appropriate!!!! One small victory for doctors.