Wiki PLEASE help me! Billing department driving me CRAZY!!

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ohn0disaster

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Stuart, Florida
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Please help!!!! I'm having problems with our office's biller. This visit is solely to establish care with the patient's newly assigned PCP.
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Vital signs: temp 98.6 b/p 110/60 r 16 p 66 wt 156

Subjective: Pt here to establish care. Pt feels well. Reports some occasional constipation. Drinks "plenty" of fluid. Reports using Miralax prn.

Objective: Gen; A, A + O x3
HEENT; nrml
CV; RRR
Pulm; CTA
ABD; soft, nt/nd, BS +
Extrem; +2 pulses, - edema

Assessment: Well Woman

Plan: check UA preg
Yaz tab PO Qday #28 #3refills
check 1000, TSH in 1-2 wk


_______________________________________

How would you code this visit?
 
There is noted extremities 2 plus edema;
requesting for UA Pregnancy-Is it for urine analysis INpregancy OR UA FOR pregnancy Test
Without mention of present status of pregancy- the Dx code would be looked for edema extremities( not mentioned whcih extremities- usually not mentioned , the physicians generally mean it is for lower extremities ; (S) he has planned for thyroid tests .
In general the info is incomplete.
Well one thing seems to be sure is there is Edema 2plus I would like to suggest 782.3 edema (whatever edema it is), as presenting symptom in the absence of other Dx. In that case, we would not go for Vcode
 
preserene said:
There is noted extremities 2 plus edema;
requesting for UA Pregnancy-Is it for urine analysis INpregancy OR UA FOR pregnancy Test
Without mention of present status of pregancy- the Dx code would be looked for edema extremities( not mentioned whcih extremities- usually not mentioned , the physicians generally mean it is for lower extremities ; (S) he has planned for thyroid tests .
In general the info is incomplete.
Well one thing seems to be sure is there is Edema 2plus I would like to suggest 782.3 edema (whatever edema it is), as presenting symptom in the absence of other Dx. In that case, we would not go for Vcode
Click to expand...

POSITIVE PULSES in both feet, NEGATIVE edema. Reread what was posted. ASSESSMENT = WELL ADULT. There is no diagnosis. V-code necessary for this visit. Biller claims that "insurances do not pay for visits using V-codes for diagnosis". I used a v-code, she claims that I am wrong. I did not want to give too much information, as to not sway any opinions. I work in office, coding, then all billable encounters get sent to billing department.
 
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