Forum - Questions & Answers

Jul 11th, 2014 - Laberube 1 

Preventive exam with sick visit

Would this be considered a combo visit if the doctor does not treat patient but refers him to specialist? A doctor sees a patient for his annual visit. In the course of the exam we noticed a large irregular pigmented lesion on the top of his head. Patient said he had this for some time. Has seen dermatology in the past. Over time it is slowly getting bigger and time to time it has yellow discharge and bleeding, Ros are done, PFSH are done. Exam itself does not does not mention lesion.
Plan: large irregularly shaped pigmented lesion not currently infected on top of head with patient reporting it is slowly changing. We will refer to plastic surgery. If there is an acute infection I did ask him to come in, otherwise see him in 6 months.

Jul 11th, 2014 - CodapediaMsgBoard 96 

re: Preventive exam with sick visit

I would bill just the preventive visit, especially if there is no exam of the lesion in the note. There is a section in CPT® that talks about this under the preventive medicine section.

It says that if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented service to report the appropriate code but an insignificant or trivial problem or abnormality that does not require additional work should not be reported.

Not sure I'd say the lesion is trivial, but the ROS and PFSH would have been done as part of the preventive, and because the exam doesn't address the lesion, it doesn't feel like there is enough additional work, when the plan is the referral or return for acute infection.

Just my two cents

Jul 14th, 2014 - Laberube 1 

re: Preventive exam with sick visit

Thank you very much for your response



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