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Thread: Establishing Care as a Chief Complaint

  1. #1
    Join Date
    Apr 2007
    Grand Canyon Coders

    Default Establishing Care as a Chief Complaint

    AAPC: Back to School
    My thought is if a patient presents to establish care, even with pre-existing problems, this is a preventative enounter, not a new problem unless the physciains or NPP is treating the problems.


    Patient presents to estalish care, being transferred from Dr. X.

    Hx: Patient has history of HTN, DMII and is significant for chronis renal failure. Recently established care with Dr Y. in nephrology. Patient has microscopic hematuria, horsehoe kidney, 1.7 cm left pelvic stone, goput and cyst to his right groin. No current concerns.

    The exam is comprehensive
    An EKG was performed (no medical necessity other than prev med). No complaints documented.
    Patient to return in 3 months to begin B12 injections. He was given literature regarding his HTN.
    No meds or other tests were performed.

    Thoughts? Please provide cites if you have them. Thanks again!

    Thanks - Schawn Pedersen, CPC, CEMC

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Preventive Exam

    From the info given, I agree, it's a preventive medicine exam.

    F Tessa Bartels, CPC, CEMC

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