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No Chief Complaint

  1. #1
    Default No Chief Complaint
    Exam Training Packages
    Hello,
    I'm interested to know how some of you would code this visit:
    CC:Patient presents for med refill. He states no complaints.
    Provider assigns DM,CHF,HTN as his clinical impression
    Lab work for A1c is done, a ROS and Phys.Exam are performed and medication
    for his chronic conditions are filled.
    The duration of the visit takes 20 min. Thank You.

  2. #2
    Location
    St. George Utah Chapter
    Posts
    40
    Default
    We see this type of office visit alot.
    1: V58.3 ENCOUNTER FOR THERAPUTIC MANAGEMENT OF MEDICATION
    2: MEDICATION PAITENT IS CURRENTLY USING
    V58.61 LONG TERM USE OF ANTI-COGAULANT
    V58.62 LONG TERM USE OF ANTI-BOTICS
    V58.63 LONG TERM USE OF ANTI-PLATELETS/ANTI-THROMBOTICS
    V58.64 LONG TERM USE OF NSAIDS
    V58.65 LONG TERM USE OF STERIODS
    V58.66 LONG TERM USE OF ASPIRIN
    V58.67 LONG TERM USE OF INSULIN
    V58.69 LONG TERM USE OF OTHER MEDICATIONS:
    METHADONE
    OPIATE ANALGESIC
    OTHER HIGH RISK MEDICATIONS
    Without seeing the progress notes, I would suggest a level III OV.
    Hopefully this is helpful.

    Melissa

  3. #3
    Default
    Thank You Melissa. It does help.

  4. #4
    Location
    St.Petersburg, Fl
    Posts
    46
    Default
    there is also a code for an encounter just for prescripiton refills
    V68.1
    Alecia Peck CPC

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