Establishing Care Visit

afields01@gmail.com

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I have a couple Docs that see patients to establish primary care. On some visits, they treat the patients and on some they are only establishing care and do not perform services. On the visit to establish that services are performed, can this be billed as preventative? And on the one that is establishing and not performing services, can this be billed as a minimal?
 

thomas7331

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This issue is brought up frequently in the forum so you might do a search and see some of the responses that have been given. My opinion has always been that 'establishing care' as a reason for a visit is not sufficient to support medical necessity for any service. This is usually an education issue for providers and staff and I've always tried to teach providers that they should not use this wording. If they are taking over management of a new patient with chronic problems or new complaints, or bringing in a new patient and performing a preventive service, then that's what should be documented. You can't code or bill a service that is performed solely for the purpose of meeting a patient and creating a medical record at a new practice.
 

erjones147

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I do not have the exact reference handy, but either the Medicare Benefit Policy Manual or the Medicare Program Integrity Manual or the 95/97 Guidelines specifically says that the term "Establish Care" is not a proper Chief Complaint. I am looking at a HRSA document using Medicare resources, but the HRSA document does not properly cite specific sources

If anyone knows the exact primary reference, I would love to have it so I can print it for my Medical Director. I trust HRSA, but there's something about "CMS" that makes ppl take notice
 

twizzle

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I do not have the exact reference handy, but either the Medicare Benefit Policy Manual or the Medicare Program Integrity Manual or the 95/97 Guidelines specifically says that the term "Establish Care" is not a proper Chief Complaint. I am looking at a HRSA document using Medicare resources, but the HRSA document does not properly cite specific sources

If anyone knows the exact primary reference, I would love to have it so I can print it for my Medical Director. I trust HRSA, but there's something about "CMS" that makes ppl take notice

'Establish Care' is definitely a chief complaint. I will provide a reference later. How many patients relocate somewhere and want routine medical care? They don't have to be sick to try and stay healthy.
 

CodingKing

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'Establish Care' is definitely a chief complaint. I will provide a reference later. How many patients relocate somewhere and want routine medical care? They don't have to be sick to try and stay healthy.

They also get an age appropriate physical which is medically necessary, its not the same as a get acquainted visit which does not follow the principals of preventive care and has no medical necessity behind it. My PCP wont see anyone until they have an age appropriate physical.
 
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twizzle

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They also get an age appropriate physical which is medically necessary, its not the same as a get acquainted visit which does not follow the principals of preventive care and has no medical necessity behind it. My PCP wont see anyone until they have an age appropriate physical.

Yes, I agree with you. Of course, having trawled the internet for the requisite information, I can't get a straight answer. What I do know is that there are two ways to view 'establish care'. It can be a reason for a visit, no question about that, but what diagnosis would you use? The provider can basically provide a goodwill visit by just taking down pertinent information (such as demographics) but not performing what may be considered a face-to-face/any elements of an E&M and not submitting a claim or charging the patient. View this as providing good customer care. When the patient does come for their first proper visit, either a sick visit or a preventive visit, they will still be a new patient and you have a diagnosis code.

The other option is to perform a new patient preventive visit which obviously must include all the requisite documentation.

At the end of the day, a visit to establish care is not a sick visit so 99201-99205 would not be used unless they want to establish care and have a problem.
 
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I have a couple Docs that see patients to establish primary care. On some visits, they treat the patients and on some they are only establishing care and do not perform services. On the visit to establish that services are performed, can this be billed as preventative? And on the one that is establishing and not performing services, can this be billed as a minimal?
I was just looking for forum related information on this same topic. I know this is an old thread, but there was an article on ICD-10 monitor that says "what you have to be careful of is a patient who presents with well-controlled chronic conditions with no complaints and is there to “establish care”. That may be considered a preventative visit to Medicare and Commercial plans." Then of course, they would have to meet the preventive visit documentation guidelines, this is the link for that article. https://www.icd10monitor.com/preventative-medicine-vs-evaluation-and-management-codes
 
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