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Thread: E&M coding - please help

  1. #1

    Question E&M coding - please help

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    I am trying to do my first E&M audit - one of my providers saw a new patient to establish and he did an office note which states NEW PATIENT HERE TO ESTABLISH...........
    He did a short history.......
    He also stated - "Pap not due until July - come in then"
    and
    he did speak with her regarding conception plans, LMP, vitals and BMI - this is all documented with an office note.
    He also no charged her since he did not do a full exam....my questions is - when she comes back in is she now established or new?

    Thanks!

  2. #2
    Join Date
    Apr 2007
    Location
    Seacoast- Dover New Hampshire
    Posts
    605

    Default E & M coding

    I would look and see if this was booked as a meet and greet appointment. We allow a 15 min appt. In our practices there are no exams done,just a face to face meet. No rx's, labs, xrays or any other tests are ordered. Hope this helps.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Join Date
    Apr 2007
    Posts
    302

    Default

    The patient encountered and presented to the clinic with a situation requiring the providers cognitive labor through coordination plans, LMP, vitals, BMI and a planned encounter down the road, which is less than three years, they would be established for the second visit and new for the first.

    Not 100% sure about this!

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