FPM Toolbox Encounter Forms Download encounter forms to help ensure accurate documentation for asthma, diabetes, hypertension, and other conditions common in primary care. Return to main toolbox page. Want to use this article elsewhere? Get Permissions. Download Format: PDF. A documentation form to identify important elements of care that are recommended for asthma visits.
The preventive medicine comprehensive examination documentation requirements represent significant work for the physician or other provider, and payer fee schedules appropriately reflect that work. CPT codes — report counseling risk factor reduction and behavioral change intervention services provided at an encounter separate from the preventive medicine examination.
Individual preventive medicine counseling codes — are used to report counseling services in areas such as family problems, diet, and exercise. New CPT codes — for individual behavioral change are available to report intervention services for patients with a behavior typically regarded as an illness, such as smoking or obesity.
Group counseling and other preventive medicine services are reported with codes — Physician practice office staff can encounter administrative challenges for accurate claims submission for preventive medicine services. Unfortunately not all third-party payers reimburse for these services. Among those who do, coverage guidelines and policies can vary greatly from payer to payer. If the physician practice has a large Medicare patient population, it is a challenge for all clinicians to stay current with the Medicare preventive medicine coverage policies.
This is crucial, because physicians are most often the ones discussing coverage issues and presenting patients with advance beneficiary notices ABNs required by Medicare when the patient is likely to be held financially responsible for a service that may be denied due to coverage policy.
For example, Medicare covers many preventive services and screenings such as cancer screenings, immunizations, and cardiovascular disease screening. In this example, described in the text, an established year-old female Medicare patient presents for a comprehensive annual exam. However, this may present challenges related to coding and reimbursement under some third-party preventive medicine payer policies.
Physician practices that approach patient visit opportunities to deliver same-day preventive medicine care and problem-oriented chronic or new illness care should consider the following suggestions:. An established year-old female Medicare patient presents for a comprehensive annual exam including screening pelvic exam, breast exam, and screening Pap test. For the purpose of this example, this patient is considered low risk under the Medicare preventive service coverage policy, and the screening pelvic and breast exams and collection of the Pap test are covered for this visit.
As shown in the table above, modifier GY is appended to code to indicate a statutorily Medicare noncovered service. All covered service fees G, Q, and are deducted from the preventive medicine service.
Physicians and their staff must do the following: Determine beneficiary eligibility including age 55 to 77, no signs or symptoms of lung cancer, cigarette smoking of at least 30 pack-years, and, for former smokers, the number of years since quitting,.
Determine whether the patient will benefit from the screening by using shared decision making, including a discussion of benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure,. Counsel the patient on the importance of adhering to annual lung cancer low dose CT screening, the impact of comorbidities, and his or her ability or willingness to undergo diagnosis and treatment,.
Counsel the patient on the importance of abstaining from cigarette smoking and, if appropriate, provide information about tobacco-cessation interventions,. If appropriate, furnish a written order for lung cancer screening with low dose CT. Written orders for lung cancer low dose CT screenings must be appropriately documented in the medical record and must contain the following information: beneficiary date of birth, actual pack-year smoking history number , current smoking status, the number of years since quitting smoking for former smokers , a statement that the beneficiary is asymptomatic no signs or symptoms of lung cancer , and the ordering physician's National Provider Identifier NPI.
The counseling and shared decision making may be repeated prior to subsequent lung cancer screening by low dose CT but must again include all of the above elements. The eligibility, frequency limitations, documentation, and bundling of preventive services may appear overwhelming. However, the IPPE and AWV are ideal visits at which to inventory which preventive services will benefit the individual patient and to create a plan for providing them.
Although the MAC for your region may not allow separate reporting of behavioral counseling services on the same date as the IPPE or AWV, the preventive visit is an ideal time to explain these benefits to your patient and obtain the patient's agreement to schedule future services.
Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Cindy Hughes is an independent coding consultant based in El Dorado, Kan. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
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Previous article. Home Care Gets a New P Jul-Aug Issue. Author disclosure: no relevant financial affiliations disclosed. Review potential risk factors for depression or other mood disorders Review functional ability and level of safety: Hearing impairment, Activities of daily living, Fall risk, Home safety. Review the patient's health risk assessment, which includes: Demographic data, Self-assessment of health status, Psychosocial risks, Behavioral risks, Activities of daily living dressing, bathing, walking, etc.
Review potential risk factors for depression. Review functional ability and level of safety: Hearing impairment, Activities of daily living, Fall risk, Home safety. Review the updated health risk assessment, which includes: Demographic data, Self-assessment of health status, Psychosocial risks, Behavioral risks, Activities of daily living dressing, bathing, walking, etc.
Conduct end-of-life planning if the individual agrees. Detect any cognitive impairment.
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