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how would you code this visit

  1. Default how would you code this visit
    Medical Coding Books
    How would you code this visit? Patient comes in for annual follow-up of her medcial problems and needs her medications refilled.

    Another example would be - Patient comes in for yearly evaluation of hyperlipidemia, diabetes II and hypertension.

    I have been coding these as problem visits and I hope that is correct. Anyone have opinions?? Thanks

  2. Default
    The above examples that I have given are specific to Medicare patients that are coming into see the doctor to renew their medications for their chronic conditions. This is the reason why we are billing the problem exams. How would you recommend the doctor state the reason for this visit?

  3. #3
    Professional Coders of Central Pennsylvania (PCOCPA), Harrisburg, Pennsylvania
    Hello mrolf! I'd say that assigning these examples as "problem visits" (regular E&M levels) would be correct. As someone that works for a health plan and focuses on Medicare Advantage billing, I'd encourage you to also be sure to code all conditions for which the patient is being seen, to each diagnosis code's highest level of specificity.
    Jennifer (Jenny) M. Oravecz, CPC
    Past Vice President/Education Officer (2012/2011) of Professional Coders of Central Pennsylvania (PCOCPA), Harrisburg, Pennsylvania
    Past President/President-Elect (2009/2008) of Professional Coders of Tidewater, Chesapeake, Virginia

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