Wiki new patient help please

[TLC]

We have a physician that is seeing a patient for the first time from China attending school here. Blue cross ppo. The patient has no problems she only came in to get a Gardasil shot. The doctor spent time with the patient going over problems/history/family history etc. How can this be billed. Since she spent time with everything can she bill as a physical? She basically did a physical, since she is new we don't know if a physical has been done previously. Or should she just bill as a new patient. But how could she code dx's since there were none? Thanks

 

[SLKappa]

Wellness with Immunization

Assuming the new pt is age 18-39:

Dx: Z00.00 Wellness Exam
Z23 Immunization

CPT: 99385 Exam
90471 with Mod 25 for Immunization Adm
90649 Gardisil (3 dose schedule, right?)

Hope this helps.

 

[Lorri62t]

Visit for Gardsil vaccine

I would try the physical but if it gets denied because the patient has had one, send a corrected claim with a NP E & M. In either case, I believe you can use Z23. But I would also like to know is there a reason why the patient is getting the Gardasil? If the patient is sexually active and at risk, then there are Dx's for problems related to lifestyle, high risk sexual behavior, etc. These start with Z72. I would probably use that first, then Z23.
Hope it helps.