Preventive Visit Plus Problem Visit Template

A patient comes in for a physical and mentions their knee, or their blood pressure reading changes the plan. That problem-oriented work is separately payable, but only if the note proves it stands on its own. This template splits the visit in two: Section A for the preventive service with the age-appropriate history and exam, counseling, and screenings ordered, and Section B for the problem-oriented service, broken into the four elements modifier 25 requires as numbered rows.

Those four elements are a chief complaint distinct from the preventive visit, an HPI specific to that problem, an exam relevant to it, and medical decision making with a treatment plan. The coding section then handles what most notes get wrong at the claim line: appending modifier 25 to the problem E/M, 99202 to 99205 for a new patient or 99212 to 99215 for an established one, and linking the problem diagnosis to the E/M line and the preventive diagnosis to the preventive line. If Section B would read as part of the physical, it is not separately billable, and the template says so on the page. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.