Wellness visit documentation

Hello,

I am wondering if anyone can point me in the direction of documentation guidelines for physicals. Is there a set # of exam points required? Does a provider HAVE to do labs and counseling?

For example pt comes in Dr. Does a breast and pelvic exam only...labs arent done at this time. Is this still a 993xx?

Or a pt comes in and Dr. does an exam on 8 systems but no labs or counseling are done...Is this a 993xx?

Any help would be appriciated as Im on the fence about this quite often.

Thanks-

ADH, CPC

Wellness visit documentation