AAPC - Back to school
Results 1 to 3 of 3

Thread: Office Visit vs Routine Exam

  1. #1

    Default Office Visit vs Routine Exam

    AAPC: Back to School
    I am trying to find out how to tell the difference between an office visit and routine exam. We have patients that will come back every 6 mos for a dm/chol/htn check and the doctor will bill a routine exam, but the insurance co will always deny (medicare) and then the patient will call stating that they just came in for their 6mo check-up. Here is a brief descp of what the physician dictated......

    CC: Diabetes and Cholestrol
    Current Problems: DM/HTN/Hyperlipdemia/Kidney Stones/benign prostate hypertrophy/dysphagia
    Family History-Done
    Past Medical History-Done
    Review Of Sytems: Recent sore throat. He took some antibotics which seemed to help. He pointed to the right side of the throat as the site of discomfort. This was going on for about two weeks but now has subsided.
    Social History-Done
    Physicial Exam- BP 136/81, pulse 77, temp 97.7 and weight was 171. HEENT-negative, The pharynx is mildly injected. No masses or nodes in the neck. Carotids are negative. Thyroid was not enlarged. Three fingerbreath larynoptosis. Chest was clear. Heart was regular. Abdomen was soft. Bowel sounds were present. No masses. No rebound. No tenderness. Extremities-negative.
    Impression-1. New onset dysphia, 2. Recent Pharynigitis, 3. DM 2, 4. Hyperlipidemia, 5. Bengin Prostatic hypertropy.
    Plan-He will follow up in six months. He will continue metformin. We will get a barium swallow and upper GI. He will start Nexium. Labs were ordered for six months exam.

    CPT: 99397
    DX: V70.0, 250.00, 787.29

    Need help if this was coded right!!! Thanks for any help!!!

  2. #2


    That is a follow up not a routine exam. A routine exam is mostly a yearly exam to make sure everything is okay... This was a follow up for sure. This should be coded 9921x

  3. #3
    Join Date
    Apr 2007
    Daytona/Orlando Florida


    eadun2000 - is correct. This is a follow up exam and should be coded 9921X (level) ? Established patient, components and time spent???

Similar Threads

  1. Routine exam, problem visit and procedure
    By MICHELLEGR in forum E/M
    Replies: 0
    Last Post: 08-11-2015, 09:47 AM
  2. New Well Woman Exam and New Office Visit
    By carolynsue2014 in forum OB/GYN
    Replies: 4
    Last Post: 11-14-2014, 09:45 AM
  3. Replies: 6
    Last Post: 09-28-2009, 08:38 AM
  4. E/M visit with routine medical exam code v70.0
    By kimb in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 10-02-2008, 05:33 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.