What you need to know about a comprehensive exam for a physical

If a male patient came in for a preventive exam, and provider documented for exam: 

Physical Examination: Wt: 204.4 lb Ht/Ln: 70 in BMI: 29.3 BP: 138/92 Pulse: 76 RR: 16 Temp: 98.9F Sat: 98 

General: Patient is alert and orientated times three in no acute distress. Well developed, well nourished and well groomed. 

Psych: Dynamic affect, makes good eye contact. 

HEENT: Head is normocephalic, atraumatic. TMs are clear bilaterally. Oropharynx is non inflamed. Tonsils are large. 

Eyes: PERRLA EOM’s intact. Lids and conjunctivae are clear. 

Neck: Supple without lymphadenopathy or thyromegaly. 

Lungs: Lungs are clear to auscultation bilaterally CV-Heart regular rate and rhythm without click, rub, or murmur. DX Z00.00.

Q: Would you consider this a preventive exam for a male patient?

A: Preventive medicine services are provided to individuals who are not in need of any immediate medical attention but need to undergo periodic health checkups as a preventive measure. Well–baby visits, well-woman visits and routine annual physical check-ups come under the purview of preventive medicine re-evaluation and management services.

These visits differ from other visits where the patient has a problem for which medical attention is sought. The age, gender and associated risk factors of the patient are important considerations while providing a preventive medicine service.

The provider uses these factors to guide taking the patient history, performing the examination and making a thorough assessment of age and gender–related risk factors. Codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.

The “comprehensive” nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the “comprehensive” examination required in Evaluation and Management codes 99201-99350. So, your exam is sufficient to bill the preventive medicine service. Just check the age of the patient to bill this section of codes.

Suggestion: If the physician found something abnormal during the preventive service and performed the above-mentioned exam for that specific condition, then in addition to preventive service the physician also can bill office visit from the section 99201-99215 with Modifier 25.