Is this enough for an EM code?

Bernadette10

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I'm not sure if this is enough for an EM code, or if the labs only should be billed:
A new patient presents for STI screening. She reports that she has never been sexually active, but her mother does not believe her before she starts college. She uses Depo-Provera for menstrual regulation. Had her 1st shot and has had menstrual irregularities.
Patient has never had a pelvic exam. After discussing with her that she does not have to get tested for STIs if she does not feel comfortable with the idea, she agreed to get blood and urine tests. She is currently on her last day of menstrual cycle and would like to avoid a speculum exam.
Patient just completed high school and will be starting college in the fall.
Pap not indicated.
Urine G/C
HIV, RPR, hepatitis blood work
Encouraged to get her 2nd Depo shot, as it usually takes 6 months to regulate menses.
RTC prn.
Three vital signs were taken by the nurse, but no other exam, and this is a new patient. I'm thinking that since there was no exam, an EM would not be billed, or can the vitals be counted as a problem-focused exam for 99201? Even though they were taken by the nurse and there's no notation that the provider reviewed them, since the provider signed the note, can this be counted as him agreeing with the nurse's findings? What if this was an established patient, would a 99212 be billable? Since he did have a discussion and decided to order the labs, I think there is medical decision making.
 

DeBillingTater

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I would argue that it is a 99402 visit, based on labs ordered and what the original reason was.

Counseling visits (99401-99404) are used for preventive STI Counseling
-No reported symptoms of infection
-Reported based on time, and uses a Z diagnosis code, in which case this can be a Z11.3

Regardless of new or established patient, E&M is not really applicable in this case.
 

Bernadette10

Networker
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Thanks, that makes sense, except I think there needs to be time documented to charge 99401, 02 etc, which wasn't done.
 
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