Wiki Preventive visit documentation

[veloso]

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.

 

[mitchellde]

I see no preventive encounter here.

 

[veloso]

Thanks a lot Debra,that's what I'm trying to explained to the Providers.