Wiki No Chief Complaint

[opiecpc]

Hello,
I'm interested to know how some of you would code this visit:
CCatient presents for med refill. He states no complaints.
Provider assigns DM,CHF,HTN as his clinical impression
Lab work for A1c is done, a ROS and Phys.Exam are performed and medication
for his chronic conditions are filled.
The duration of the visit takes 20 min. Thank You.

 

[Melissa_M]

We see this type of office visit alot.
1: V58.3 ENCOUNTER FOR THERAPUTIC MANAGEMENT OF MEDICATION
2: MEDICATION PAITENT IS CURRENTLY USING
V58.61 LONG TERM USE OF ANTI-COGAULANT
V58.62 LONG TERM USE OF ANTI-BOTICS
V58.63 LONG TERM USE OF ANTI-PLATELETS/ANTI-THROMBOTICS
V58.64 LONG TERM USE OF NSAIDS
V58.65 LONG TERM USE OF STERIODS
V58.66 LONG TERM USE OF ASPIRIN
V58.67 LONG TERM USE OF INSULIN
V58.69 LONG TERM USE OF OTHER MEDICATIONS:
METHADONE
OPIATE ANALGESIC
OTHER HIGH RISK MEDICATIONS
Without seeing the progress notes, I would suggest a level III OV.
Hopefully this is helpful.

Melissa

 

[opiecpc]

Thank You Melissa. It does help.

 

[apeck]

there is also a code for an encounter just for prescripiton refills
V68.1