Wiki No chief complaint - chronic conditions

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opiecpc

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Patient is 64 y.o. estab.patient with 2 chronic conditions, HTN and DM. DR. states in his HPI patient has no complaints and no new problems. For his assessment the Dr. assigns HTN and DM. Would this be coded as preventive med. 99396? Thank You for your answers.
 
I would believe that if there were no chief complaints that this would be a Physcial..I would check the office note to verify.
 
No Chief Complaint

I have the same 2 conditions and see my doctor every three months. Unless I go specifically for a physical, my visits are always billed in 9921_ sequence. HTN and DM are conditions that require upwards of 4-6 visits a year depending on whether they are controlled or not. I would urge you to educate your doc that when a patient comes in for follow-up of chronic conditions such as the above, it is important to state that while the patient may not have any current complaints, they are being seen for HTN and DM.

Joyce
 
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