Hi I have been trying to get a better understanding regarding awv and e/m ov billed together. This patient is new and dr coded 99385 and 99202. No additional workup was done for back pain so I was just going to bill the 99385 and wanted to know if that is correct.
Assessment
1. Encounter for preventive health examination (Z00.00)
Pt doing well overall.
Pt UTD on vaccinations
Pt UTD on pap smear
Recommend annual vision exams, dental exams, and consider dermatology appt in
future
Will check routine screening labs today
Encouraged pt to eat healthy, balanced meals, engage in regular exercise, and get
adequate sleep.
Depression screening performed
2. Chronic bilateral low back pain without sciatica (M54.50,G89.29)
Following with PT for chronic back and hip pain
Consider MRI/ortho in future for persistent issues
3. Chronic sinus complaints (R09.89)
Referral to ENT for further eval and management
Plan
CBC, w/ Differential; Status:Active; Requested for:07Apr2023;
CMP Complete Metabolic Profile; Status:Active; Requested for:07Apr2023;
HEMOGLOBIN A1c WITH Eag; Status:Active; Requested for:07Apr2023;
Lipid w/ Direct LDL; Status:Active; Requested for:07Apr2023;
TSH w/rlfx to Free T4 - LC 349829, Q 6127, OR43562; Status:Active; Requested
for:07Apr2023;
15 min outside annual spent discussing back pain, sinus issues
Patient Plan/Instructions
F/u prn
Chief Complaint
CPE.
History of Present Illness
Pt here to re-establish care and CPE
Pt with chronic sinus issues
Recently had "sinus lift" surgery and reports daily sinus sx
Recently had dental surgery as well
No previous consultation with ENT
Assessment
1. Encounter for preventive health examination (Z00.00)
Pt doing well overall.
Pt UTD on vaccinations
Pt UTD on pap smear
Recommend annual vision exams, dental exams, and consider dermatology appt in
future
Will check routine screening labs today
Encouraged pt to eat healthy, balanced meals, engage in regular exercise, and get
adequate sleep.
Depression screening performed
2. Chronic bilateral low back pain without sciatica (M54.50,G89.29)
Following with PT for chronic back and hip pain
Consider MRI/ortho in future for persistent issues
3. Chronic sinus complaints (R09.89)
Referral to ENT for further eval and management
Plan
CBC, w/ Differential; Status:Active; Requested for:07Apr2023;
CMP Complete Metabolic Profile; Status:Active; Requested for:07Apr2023;
HEMOGLOBIN A1c WITH Eag; Status:Active; Requested for:07Apr2023;
Lipid w/ Direct LDL; Status:Active; Requested for:07Apr2023;
TSH w/rlfx to Free T4 - LC 349829, Q 6127, OR43562; Status:Active; Requested
for:07Apr2023;
15 min outside annual spent discussing back pain, sinus issues
Patient Plan/Instructions
F/u prn
Chief Complaint
CPE.
History of Present Illness
Pt here to re-establish care and CPE
Pt with chronic sinus issues
Recently had "sinus lift" surgery and reports daily sinus sx
Recently had dental surgery as well
No previous consultation with ENT