Wiki V70.0 and general office visits

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jliving77

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Our office sees a lot of refugee patients. They come here for everything. We see a lot of kids for the WCC's and sometimes they come back 2 months later just to "check in", they have no medical concerns or issues. The pt checks out fine and my provider documents a 'general exam', 'routine exam' or 'physical exam'. Aside from the fact that that pt may have already had their EPSDT or PE within the allowed time period, the provider is not documenting what is necessary to bill a 9939x or 9938x. Basically I am left with a patient who just came in to have the provider tell them everything is still fine, again the "pt has no concerns or complaints at this time" so I can't bill a "worried well" visit. There is that rare case where the parent is afraid there is something minor wrong because they didn't understand the lab work that came back but otherwise there simply is nothing addressed at these visits.
How in the world am I supposed to bill this?? These patients have Az State AHCCCS (medicaid).
Can I bill a V70.0, or V20.2, with a 9921x? I don't think I can but I would really appreciate some knowledge from some other coders.
Thanks guys!!:)
 
I think so, it is hard to say without the chart note but from what you have described the patient is wanting just a follow up encounter for whatever reason. The guidelines state follow up means the problem is not active and is currently not being treated. You state they already had the EPSDT or PE and just want to follow up to make sure all is still good.
 
Here is what my provider documented. Maybe from the CC this is where I can take the V67.59 from? I would think that this would only be a 99212 though not a 99213 that my provider entered.

Visit Type: Follow-up Visit

CC: physical exam f/u.

History of Present Illness:
Father (through translation device) states child eats all foods given but in small amounts. Father has no specific concerns but states that caseworker told him to come. Child is playful, smiling and inteeractive during entire interview.





Review of Systems
General: Denies fevers, chills, sweats.
Eyes: Denies discharge, vision loss, eye pain.
Ears/Nose/Throat: Denies earache, decreased hearing, nasal congestion, sore throat, difficulty swallowing.
Cardiovascular: Denies paroxysmal nocturnal dyspnea, chest pains, palpitations, near fainting, SOB on exertion, swelling of hands and feet.
Respiratory: Denies cough, SOB.
Gastrointestinal: Denies change in appetite, nausea, vomiting, diarrhea, constipation, change in bowel habits, abdominal pain.
Genitourinary: Denies painful urination, blood in urine, urinary frequency, nocturia.
Musculoskeletal: Denies joint pain, joint swelling, muscle weakness, muscle aches.
Skin: Denies rash, skin cancer, suspicious lesions.


Physical Examination
T: 98.2 oral P: 65 RR: 22 BP (upright): 96 / 64 Wt: 36.5 Height: 43.5

Constitutional: Alert, no acute distress, well hydrated, well developed, well nourished. SLENDER BUT HEALTHY-APPEARING
Skin: Normal turgor, normal color, no rashes, no lesions, no unusual bruising.
Head: atraumatic, normocephalic.
Eyes: EOM intact, PERRLA, no injection, vision grossly normal.
Ears: R ear normal, L ear normal, no external deformities, canals clear, TM's pearly gray, gross hearing intact.
Nose: non-tender, normal mucosa, septum midline, turbinates normal.
Mouth: good dentition, no erythema, no exudates, no lesions.
Neck: supple, no adenopathy, no masses, thryroid normal size, no thyroid tenderness or nodules, normal neck ROM.
Cardiovascular: RRR, no murmurs, no gallops, peripheral pulses intact, no edema.
Respiratory: No respiratory distress, no accessory muscle use, clear to auscultation.
Abdomen: nondistended, nontender, normal BS, no hepatosplenomegaly, no hernias.

Orders Added:
Level 3 (15) (detailed) [99213]

Impression & Plan:
1. PHYSICAL EXAMINATION.
Slender, healthy-appearing child
Immunizations current
Has been to dentist.
 
99213 with V70.9 (unspecified general exam) is what I would code based on that documentation.
The level HPi: Brief ROS: Extended = EPF exam
PE: Detailed
MDM: None

2 out 3 components would level to 99213
 
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