New patient with established care

NaliniAAPC

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Hi,

Patient comes in to establish care with Dr. Dr wants to bill an E/M visit, new patient. In HPI all his conditions are stable and taking madication for htn, patient has no complaints. Dr does comprehensive PFSH and comprehensive EXAM and Mod MDM. Can we bill an level of service? New patients require 3 of 3 components, without the HPI, how can we bill a level of service? Any opinions would be greatly appreciated.

Thank you,:)
Nalini CPC
 

mitchellde

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your history is HPI ROS and PFSH, it sounds like you have a focused history due to HPI, even with the comp exam and moderate MDM the visit is a 99201.
 
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Or ...

Or ... it might be a preventive visit. Hard to tell without seeing the full documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

NaliniAAPC

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Hi,

Thanks Tessa and debra.Yes you are correct, i have coded as preventive care.

Thanks,
Nalini CPC
 
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