tci E/M Coding Alert - 2020 Issue Q2

Reader Question: Use This Answer to Code Split Preventive Services

Question: If a patient was seen by her Primary Care Physician for an annual checkup, no pelvic or breast examination, we bill the visit with the preventive CPT® code 99395 with DX Z00.00. Patient returns two weeks later and sees a Primary Care NP in the same practice for a breast/ pelvic examination and Pap smear. Should I bill this visit with a problem E/M with the DX Z12.4? Patient did not want the Primary Care Physician to perform the pelvic examination. The insurance is also commercial, so Q0091 is not billable. Florida Subscriber Answer: First...

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