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Preventive or problem-focused visit, this is a different scenario

  1. #1
    Default Preventive or problem-focused visit, this is a different scenario
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    Not sure how to code this visit. 9 year old patient had a well child visit on 07/30/2018, but would not let the female provider perform the genitourinary exam due to history of sexual abuse. Returned on 08/08/2018 to have this exam performed by a male provider. Male provider also explained puberty and physical changes the patient would be experiencing in the next few years. Does this warrant a preventive visit or problem-focused? Can we code a preventive visit that soon? Can I code a problem focused e/m with Z00.3 and Z62.010. Any thoughts would be greatly appreciated.
    penny0222

  2. #2
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    Does anyone have any thoughts on how to code this visit? We are at a loss. Three of us. Any help would be greatly appreciated.
    penny0222

  3. #3
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    I would not charge for the second visit. If the charge for the initial visit was for a comprehensive preventive service which could not be completed, then your practice has already been reimbursed for the additional preventive services that were deferred and performed by the provider at the second visit. Under the circumstances, charging a problem E/M at the second visit without a new complaint or change in condition would be incorrect coding and also, in my opinion, poor customer service that would likely generate a complaint.
    Thomas Field, CPC, CEMC

  4. #4
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    Medical Billing
    Mr. Field,

    Exactly what I was thinking. Just needed some reassurance, however, was wanting to get the second provider some reimbursement for his time spent.

    Thank you, again.
    penny0222

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