Wiki Well Visit and Sick Visit

[veloso]

Hi All, In 2023 changes does this HPI acceptable/ billable for Well Visit and Sick Visit (Progress Notes with complete ROS and Physical Exam) ​ HPI; 47 yo male with T2DM presenting today to establish care new PCP physical exam. Assessments 1. Encounter for general adult medical examination with abnormal findings - Z00.01 (Primary) 2. Tobacco abuse counseling - Z71.6 3. Tobacco use - Z72.0 4. Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin - E11.40 Treatment 1. Encounter for general adult medical examination with abnormal findings LAB: CBC With Diff/Plt (def) LAB: Comp. Metabolic Panel (def) LAB: Hemoglobin A1c (def)* LAB: HAV Ab, Total LAB: Lipid Panel (def) LAB: Measles/Mumps/Rubella Ab IgG LAB: Urinalysis, Routine (def) LAB: HBV Evaluation Profile LAB: HCV Antibody With Reflex to Quantitative Real-time PCR LAB: QuantiFERON-TB Gold Plus 2. Tobacco abuse counseling Notes: Greater than 3 minutes, but less than 10 minutes spent counseling Discussed the importance of quitting smoking to help lower risk of heart disease, lung disease and stroke. Also discussed financial benefits of quitting smoking. Pt may live longer and healthier and may even have more energy when they quit Quitting strongly encouraged. 3. Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin Start metFORMIN HCl Tablet, 500 MG, 1 tablet with a meal, Orally, twice a day, 30 day(s), 60 Tablet, Refills 0 LAB: Microalb/Creat Ratio, Ur (def) Referral To:Opthalmologist ReasonM eye exam Thank you All in advance!

 

[taysin93]

PHYSICAL AND OFFICE VISIT SHOULD BE BILLABLE AS
99386
99203 (25)

 

[veloso]

Thanks a lot for the reply!!!