• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

Preventive visit documentation

veloso

Guru
Messages
216
Best answers
0
Is this an acceptable documentation to bill for a separate Preventive Visit?
Chief Complaint(s):
Pt is here for annual PE as well as for sick visit for eval of reg medical problems ... see HPI .
HPI:
Clinic Visit
Pt c/o burning sensation around his anus & into penis x's past 1 wk ... no d/c ... + burning on urination x's 1 wk as well ... this is a new problem with BM though "I do strain on passing BM" ... no F/S but + c/o chills occasionally x's past 6 months but no wt chages ...
ASSESMENT:
1.ROUTINE MEDICAL EXAM
Flu shot given 10/3/09 ... H1N1 given @ work 12/09 ... PNA given 12/30/09 ... up-to-date with colonoscopy
2.URINARY PROBLEMS NEC
Start Bactrim DS Tablet, 800-160 MG, Orally, 6, 1 tab, twice a day, 3 day(s), Refills 0Lab:URINALYSIS, COMPLETE

PHY.EXAM;ROS COMPLETED

My question is this,if during the Preventive Visit there's no LAB ORDERED,no COUNSELING provided if it's still qualifies for a Preventive Visit?

Thanks.
 
Top