E/M vs. Preventative Family Planning Visit

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358
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Malone
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How would you code this visit? E/M or Preventative. If Preventative, can I get away with coding an additional E/M based on evaluation of patient for insomnia and subsequent prescription? Insomnia is has been a problem since visit the year before. The lack of HPI and ROS is what bothers me about coding the visit. No Comprehensive History component.


CC: Annual PE and Pt would like referral for Vasectomy
HPI: Wife wants to go off pill. Interested in birth Control
PMH: Lumbar Disc Disease
Surg Hx: 0
Allergies: NKDA
Social H: Married, No tobacco use, alcohol socially
ROS: sleep problems
Vitals Documented
Exam:
General: Normal
Head: Normal
Eyes: Normal
Neck: Normal
Chest: Normal
Breasts: Normal
CV: Normal
Abdomen: Normal
Back: Full ROM, non tender
Ext: Normal
Skin: Normal
Neuro: Normal
Assessment: Family Planning, Insomnia, Lumbar Disc Disease
Plan: Urology Consult, Lunesta RX


Thanks for your input.
 
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170
Location
Fontana
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the lack of info bothers me, too lol lol
okay it's only a preventative....there has to be an HPI/EXAM/MDM of the pertinent problem (s)....looks like this MD referred pt to URO to handle the vasectomy...don't see any mention of insomnia

How would you code this visit? E/M or Preventative. If Preventative, can I get away with coding an additional E/M based on evaluation of patient for insomnia and subsequent prescription? Insomnia is has been a problem since visit the year before. The lack of HPI and ROS is what bothers me about coding the visit. No Comprehensive History component.


CC: Annual PE and Pt would like referral for Vasectomy
HPI: Wife wants to go off pill. Interested in birth Control
PMH: Lumbar Disc Disease
Surg Hx: 0
Allergies: NKDA
Social H: Married, No tobacco use, alcohol socially
ROS: sleep problems
Vitals Documented
Exam:
General: Normal
Head: Normal
Eyes: Normal
Neck: Normal
Chest: Normal
Breasts: Normal
CV: Normal
Abdomen: Normal
Back: Full ROM, non tender
Ext: Normal
Skin: Normal
Neuro: Normal
Assessment: Family Planning, Insomnia, Lumbar Disc Disease
Plan: Urology Consult, Lunesta RX


Thanks for your input.
 
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4,456
Location
Milwaukee WI
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Too Bad there's No Time noted

If time spent w/ the patient had been noted, along with a statement that more than 50% of that time was in counselling/coordination of care you could bill the E&M services based on time.
F Tessa Bartels, CPC
 
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