Wiki New Patient

[HBULLOCK]

We have a new patient that came in to establish primary care. Has multiple medical issues. Premature infant (currently 6 months old) with Hx of stroke, laryngomalacia, hypernatremia etc. As he came in for a med refill and to establish a new DR what diagnosis would you code? Documentation speaks of all issues and current meds patient is on. Thanks

 

[mitchellde]

sounds like a routine visit, as there is no symptomatic complaint so you can use the V20.x or you can use the V code for medication refill.