Primary Care Coding Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: A new patient came in for a consultation for establishment of care. The FP spent 20 minutes telling the patient her outlook on health maintenance and health promotion. She also discussed preventive medicine as an option contrary to disease management. No examination was performed. Am I correct to code the encounter 99202 for a new patient visit?

Arizona Subscriber

Answer: This visit, often referred to as the "get- acquainted visit," should not be coded 99202 (office or other outpatient visit for the evaluation and management of a new patient ...). The new patient E/M code requires the physician to perform an examination and medical decision-making. In your case, the FP only discussed health management with the patient. It should be coded 99401 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) and V65.49 (other counseling, not elsewhere classified; other specified counseling).
 
The preventive medicine E/M code accounts for the patient counseling, and the V code is the reason for the visit. Code 99401 is also more appropriate than 99202 due to the absence of any patient complaint.