Preventive Services

April 26th, 2022 - Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
Categories:   Audits/Auditing   Preventive Medicine Service  

In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding the lack of interpretation about what is truly a “preventive service”.

A good definition of Preventive Care is from CIGNA’s website: “Preventive care helps detect or prevent serious disease and medical problems before they become major”. There are several different great definitions on different carrier websites, but the whole purpose of a preventive wellness exam is trying to prevent serious disease or injury for that patient. When we have a patient that’s looking for refills of their medication, that is not a preventive wellness exam. If a patient has an insignificant complaint, that is not a preventive wellness exam. So, we do have a lot of wellness exams in which these issues are being taken care of during the wellness exam -or that is part of the wellness exam. Those are actually sick visits. Now I know, I know. You’re all cringing. There are some commercial carriers that have very specific policies that do not pay for sick visits in conjunction of wellness visits. If an insurance carrier has a policy that says they do not pay for both at the same time, then you would be smart to not handle both at the same time, or to handle both and just understand you’re not going to get paid for both. We’ve had providers tell us “you don’t understand, If we don’t do the preventative when the patient is here, they are not going to go back for the preventive”. I don’t know about you, but I probably fall into that ballpark. I’m not the best patient at going in for those preventive wellness appointments! But my point is take care of the patient, do what’s best for the patient, of course, but a patient is in the office for a preventive wellness visit and asks for a refill of these medications -and the provider agrees to refill those meds for, and I see at the bottom of the encounter “refill for XYZ”, I can’t automatically assume that’s an additional billable E&M encounter. That’s just refill of meds with a wellness visit. However, if the provider documents as if this is more of that encounter; “Let’s talk about those problems”. So, let’s say maybe it’s a sleeping medication. “Are you still having trouble sleeping? Well, what have you done for that? Have you tried meditating at night? Have you tried turning your TV and your electronics off at night?” You can see there’s a follow up about those chronic comorbidities or whatever those issues are. There’s a follow up visit. That follow up visit is billable in addition to the wellness visit.

Lastly, I would like to talk about Medicare preventive. What we have been seeing more commonly than not on audits, are a lack of specific components that are outlined as required components as part of that Medicare wellness. You guys need to go check, especially if you have predetermined templates as part of your EMR process, go check your templates. Two areas to specifically check that we keep seeing routinely missing, especially on SWV’s and a ABV’s, is your annual wellness visits and your subsequent wellness visits. We are commonly seeing a lack of an updated list, especially on SWV’s, of all your providers and a specialized preventive wellness plan that is supposed to be specific to the patient, and by the way, just listing some of their providers for some of their specific diagnosis, that’s not an updated comprehensive list of their suppliers and their providers. You are supposed to give an updated list of all of their physicians. If they don’t have any, and I audit the note and you didn’t list it, just saying. “Well, they didn’t have any”, then you should be documenting that. So again, be inclusive with your documentation of what requirements are supposed to be there.

Thank you for sharing this time with me today. You can also view the video on this topic here. Please give us your comments and also don’t forget I’m available if you need me. Drop me an email at and you can visit the NAMAS website for more information about our audit services.


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