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Wiki Sick/well on same date

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williafm

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Help. Disagreement with co coder .
I have an np that did a well woman and found a lump in the pt breast. She ordered an us . I have no hpi as there was no complaint. I have no exam above the normal breast exam. All i have is mdm of moderate for new prob with work up. I say sick visit isnt billable because there is only 1 of 3 not 2 of 3. My co coder says she can bill the sick because she's doing additional work up.
 
sick/well same date

Let me ask a question, Provider finds lump in breast on exam, she also finds hemorrhagic cyst at right introitus, 1 cm and cervix, relaxation , adnexal fullness. The provider orders diagnostic mammo, ultrasound of breast and ultra sound of pelvic and transvaginal. She does have abnormal exam findings on the normal exam bullets you would do for a well woman and her MDM she is ordering diagnostic testing. If not now when would you do a sick and well visit?
 
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