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Wiki Chief Complaint: Follow Up

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acbarnes

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I am trying to break my physicians of stating, "Here for follow up" as a chief complaint. I have an MD (Colorectal Surgeon) who brings patients in yearly to "follow-up". For example, a patient had a LAR for diverticulitis last year. Our MD recalls him for a yearly visit just to see how he is doing. The patient is doing well with no complaints. He does not schedule a follow up colonoscopy just asks the patient to return again next year.

I do not see a medically necessary complaint for E/M. What about V67 Follow-up exam as diagnosis? What CPT would you use? I am leaning toward non billable service. Any suggestions?

Anna Barnes, CPC, CEMC
 
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