Question New Patient

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When you are seeing a New Patient with no concerns just needs immunizations, what level E/M would you code? What HPI element could you count (location, quality, severity, context, etc.)? I need at least one to code even a 99201. HPI states:

12 Months Old
40 weeks. Maternal hypertension. No complications with delivery. To newborn nursery and home. No known complications with birth or delivery.
Patient is not up to date on immunizations and mother would like these to be given today.
No concerns.
 

thomas7331

True Blue
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There should be no E&M service charged if the patient has only come in for immunization. Any evaluation required for the immunization is considered integral to the service. A new patient E&M, 99201-99205, is by definition a problem-oriented visit which requires a chief complaint and would not be appropriately coded if the patient presents with no complaints and for preventive care only.
 

Tami_F

Networker
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There should be no E&M service charged if the patient has only come in for immunization. Any evaluation required for the immunization is considered integral to the service. A new patient E&M, 99201-99205, is by definition a problem-oriented visit which requires a chief complaint and would not be appropriately coded if the patient presents with no complaints and for preventive care only.
Agreed, this sounds like preventive care (CPT 99381-99397). These codes are age-based, and differentiate between new and established patients.
 
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Agreed, this sounds like preventive care (CPT 99381-99397). These codes are age-based, and differentiate between new and established patients.
Patient had already had a preventative. We are a FQHC and are paid a PPS rate based on a face to face encounter with a provider. The doctors wants to receive the payment for the encounter but I don't feel this meets criteria for an office visit. The HPI is all about the mother the only portion regarding the child is needs vaccinations and I don't feel this meets criteria for an HPI. If so please tell me what element you would use to at least get one element (location, quality, timing, duration, mod. fact., etc.) to meet a 99202 for a new patient because I'm not seeing it.
 
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