Preventive/New Patient

NESmith

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CC-New patient to establish,referral for mammogram.
HPI-Pt is a 62 yr old female. New pt.to establish care. HTN/High chol/patient on Weight Wathcers. Pt having breast pain on the rt side, last mammogram was 2 yrs agao. last labs 6 months ago. pt wants Wellness visit.
Past Medical/Surgical Hx
Reported Hx:
Pregnancy: Gravida 2
Diagnosis HX:
Hypertension
Hyperlipidema
Therapeutic Hx:
Cholecystectomy
Hysterectomy
Social Hx:
Behavioral: Caffeine use 2 cups of coffee daily. Not smoking. A previous hx of smoking quit 6 yrs ago.
Alcohol: Alcohol use socially
Drug Use: Not using drugs
Habits: Good exercise habits
Work: retires
matial: Currently married
Functional: No physical disability
ROS:
Cariovascular: No symptoms
Pulmonary: No symptoms
GI: No symptoms.
Pertinebt positives and negatives as stated in the HPI; otherwise negative in all 14 systems as reviewed with the patient.
Physical Findings:
Vitals
Heneral Appearance:
Oriented to time, place ad person in no acute distress.
Neck:
Suppleness: The nek demonstrated no decrease in suppleness.
Thyroid: The thyroid showed no abnormalities.
Lungs:
Normal breath sounds/voice sounds, no wheezing was heard, no rhonchi were heard, and no rales/crackles were heard.
Cariovascular:
Heart Rate and Rhythm: Heasrt rate and rhythm normal
Heart Sounds: S1 nomral and the S2 was normal
No murmurs were heard.
Edema not present.
Neurological:
Speech was normal
Gait and Stance were normal.
Psych: Affect was normal
Skin: Skin temperature was normal.
Assessment:
Pain in Rt breast-Possible M/S as pt started exercise and diet program.
last mamogram was 2 yrs ago
Normal routine Hx and Physical
Essential Hypertension-last labs was 6 months ago. Ordered. Atenolo/HCTZ 50/25 g q day request 90 days refill
Hyperlipidema-labs orderd Lovastatin 20 mg Q eve. refilled per pt request
Plan:
Mammogram ordered. labs ordered
Dx HTN/High Chol
OK, after all of that my question is; would you code this as a Preventive or New Patient. My provider did both. I don't feel this is correct. Thanks for your help as always.
 

KKNOX

Contributor
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I would have the V70.0 code moved to the priamry diagnosis, since it is a primary diagnosis only and for the E&M I would code the 99386 along with 99201 with modifier 25 to say the doctor went above and beyond the preventative medicine visit with an acute symptom such as the breast pain. I counted the chronic conditions as part of the wellness visit. Hope this helps.
 
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