Wiki RX Refills & Wellness Labs

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Coder85

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Can someone help me with the following scenario?

The PT comes in for HTN RX Refills however, during the visit the Provider realizes that the PT "has not had wellness labs drawn" for several years now and, therefore, decides to order labs which include CBC, chem, TSH, HbA1c, etc.

In her Assessment she documents
HTN & 401.9
Physical examination v70.0

Is this really considered a PE?
Would I bill both a 99212 and a Preventative 9939X?
Or just an Office Visit?

Please help!:confused:
 
If he only orders labs then you would use V72.62 lab examination part of general medical exam. You would bill the appropriate CPT code for the follow up visit of hypertension management DX 401.x and V68.1 for the issue of repeat rx.

To bill a preventive exam the following is needed:
A comprehensive history and physical examination,
Anticipatory guidance, risk factor reduction interventions or counseling,
The ordering of appropriate immunizations or laboratory/diagnostic procedures,
Management of insignificant problems.
 
Last edited:
Thank you so much for the information!

So that means that in the above example which does not meet the requirements for a preventative exam, I would code the following...

401.9
v68.1
v72.62

Correct?
 
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