If the patient was scheduled for a preventative exam, but wound up having complaints that are addressed or an abnormal discovery was found during the exam, you would code those under your sick visit E/M code 992xx with mod 25. The preventative exam only gets the V70.0. This is call a split bill-you split out the sick visit from the well visit. Per CMS rules the total amount of E/M charges for this visit cannot exceed the cost of the preventative code charge. What you have to do is leave the price of the sick E/M code at full price and adjust the price of the preventative code. Ex:99397=$350 and 99213 mod 25=$80. You would bill 99213 $80 and 99397 $270 for the total charges of E/M on this dos as the total price does not exceed $350. You only need to pull out the pertinent elements to support the sick part of the visit to decide what level your code will support. The rest of the head to toe exam falls under the preventative part of the visit. If the patient has chronic illnesses and is on medication you can list these separately under the sick visit as long as the doc is addressing them today. A medication refill counts as the sick visit as well.