tci E/M Coding Alert - 2021 Issue Q1

Preventive Medicine: Prevent Documentation Problems With These 99381-99396 Recommendations

Code descriptors only tell part of the story. You know that preventive medicine E/M services are important, so you may be surprised to learn that “there are no official, specific documentation guidelines” for 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/ diagnostic procedures …) according to Ellen Hinkle, BS, CPC, CDEO, CPMA, CRC, CEMC, CFPC, CGSC, CIMC, COBGC, CPCD, AAPC Approved-Instructor, provider compliance auditor at Bon Secours Mercy Health Cincinnati, Ohio. CPT® descriptors for the...

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