If a PE wasn't performed, I (personally) would go with the 1st one.
Q Is there a code for a "get-acquainted" visit with a new patient?
A No. These services would not be considered medically necessary or preventive and should not be billed to the insurance. Unless your policy is to provide these visits at no charge, patients should be informed when they call to schedule this type of visit that insurance will not cover it and that payment will be expected at the time of service.
"Get acquainted" visits
Q: When a patient comes for a "get established" visit with no serious complaints we are coding as an annual exam. Are there separate procedure charges for the breast exam, prostate exam, etc.? Or are these global in the E&M code? If so, should modifier -25 be used anywhere?
A: There is no CPT code for a "get acquainted" visit, so you'll need to perform a true well-male or well-female check in order to bill for these. If you are, the likelihood is that all of the services (e.g., DRE) are indeed included in the E&M. That would exclude lab services, which you would bill for separately, but don't need a modifier. Modifier -25 is limited to noting a "separately identifiable" E&M service - which is used when you have a separate diagnosis; therefore, you need to point out that you've actually performed two services during one encounter (because the patient has two distinct needs).
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