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how would you code this visit

M

mrolf

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West Point, NE
How would you code this visit? Patient comes in for annual follow-up of her medcial problems and needs her medications refilled.

Another example would be - Patient comes in for yearly evaluation of hyperlipidemia, diabetes II and hypertension.

I have been coding these as problem visits and I hope that is correct. Anyone have opinions?? Thanks
 
The above examples that I have given are specific to Medicare patients that are coming into see the doctor to renew their medications for their chronic conditions. This is the reason why we are billing the problem exams. How would you recommend the doctor state the reason for this visit?
 
Hello mrolf! I'd say that assigning these examples as "problem visits" (regular E&M levels) would be correct. As someone that works for a health plan and focuses on Medicare Advantage billing, I'd encourage you to also be sure to code all conditions for which the patient is being seen, to each diagnosis code's highest level of specificity.
 
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