Wiki documentation question

[mistyrich]

We just opened a new student health clinic on our university campus; it is a combo PCP/walk-in/urgent care for students only. I just saw that our 2 providers have not documented that each student is a new patient. We have been mainly seeing patients for cold/flu and STD testing so nothing extraordinary. The providers don't say they are new patients in the documentation and the visits are pretty short (20 minutes or less). My question is, should I code for new patient or established and do I need the providers to amend their notes?

Thank you in advance for your help!

 

[michrpree@yahoo.com]

To my knowledge they should be putting that it is an initial visit but I do not think that is required to code a np visit. Just as long as the patient has not been seen within the last 3years should be enough. I am not positive though.

 

[mistyrich]

Thank you for your reply! I figured it out, my front desk staff were not putting new or established in the appt choice.

 

[jkyles]

I'd just add that it is unlikely that a physician will know whether a patient is new or established, given the three year time gap. Having front desk staff keep tabs is the way to go.