A patient was seen for an E/M visit. Clinician recomended the patient return in 3-4 months to discuss scheduling routine labs. Patient's DX were CP, MR, Seizures. Patient returned only 3 weeks later. Documented reason for visit was "F/U labs - CP, MR, Seizures". Doctor documented "patient feels good, no concerns, ? labs" Examined 10 systems, assessment "Seizures, MR Stable"
Plan " Continue current tx, RTC 2-3 months" and ordered lab work.

I am concerned because there doesnt seem to be adequate justification for the visit. The provider feels that since he ordered lab work, we are okay to bill the visit. It was not a "F/U labs" because there were no new labs to review.

How would you code this visit? Was there justification for the visit?

Thank you for your input everyone