We had a young patient from out of the area come here with her mom just to establish care. I know that the CPT code is a regular office visit but I can't figure out what to bill for the DX code as the patient didn't have a pelvic exam or pap smear. I'm at a loss of how to code this. Can someone help me?
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Wiki Establish Care DX Code
- Thread starter kenkie79
- Start date
Pam Warren
True Blue
If there's no chief complaint, then you wouldn't code a problem visit. You'd code a preventive visit.
We caution our providers with regards to this. Often patients want a meet & greet. That's not medically necessary according to the payers.
We caution our providers with regards to this. Often patients want a meet & greet. That's not medically necessary according to the payers.
Mcsalazar00
New
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So if there is no cheif complaint then this is not billable. provider is billing a 99212 with z71.89
thomas7331
Guest
Per the guidelines, a chief complaint can be simply a medically necessary reason for the visit documented by the provider - it doesn't necessarily have to be an actual 'complaint' by the patient. But the provider does have to document why the E/M service is being done. If it is missing or unclear, then I'd probably query the provider for additional information rather than making it 'not billable'.
Chief Complaint (CC)
A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.