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E/M or Preventative

  1. #1
    Wink E/M or Preventative
    Medical Coding Books
    I need some second opinions.

    I have this:
    99202 dx V70.0 V04.89 V05.3 V05.4
    90633 SL v70.0 V05.3
    90716 SL v70.0 v05.4
    90658 SL v70.0 V04.89

    I look at the notes to check for a CC and I see
    Reason for visit :Well Child Check, establish care
    10 year old girl here with mom to establish.
    Sleeps well and eats well. Is doing well in school. Enjoys reading and swimming. Enjoys her friends. Drinks a lot of water. Occasionally has sodas. Has periodic sore throats. No nasal congestion.

    HPI Comments: No sore throat symptoms today.

    Review of Systems
    Constitutional: Negative for fever and chills.
    HENT: Negative for ear pain, nosebleeds and congestion.
    Respiratory: Negative for cough and shortness of breath.
    Cardiovascular: Negative for chest pain and palpitations.
    Gastrointestinal: Negative for nausea, vomiting, abdominal pain and diarrhea.
    Genitourinary: Negative for dysuria and urgency.
    Musculoskeletal: Negative for myalgias and joint pain.
    Skin: Negative for rash and itching.
    Neurological: Negative for dizziness, tingling, tremors and headaches.
    Endo/Heme/Allergies: Does not bruise/bleed easily.
    Psychiatric/Behavioral: Negative for depression. The patient is not nervous/anxious and does not have insomnia.


    Filed Vitals:
    12/30/2010 2:51 PM
    BP: 110/60
    Pulse: 70
    Temp: 98 °F (36.7 °C)
    TempSrc: Oral
    Resp: 10
    Height: 4' 10" (1.473 m)
    Weight: 90 lb (40.824 kg)
    SpO2: 98%

    Physical Exam
    Constitutional: She appears well-developed and well-nourished.
    Right Ear: Tympanic membrane normal.
    Left Ear: Tympanic membrane normal.
    Nose: No nasal discharge.
    Mouth/Throat: Mucous membranes are dry. Oropharynx is clear.
    Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, and reactive to light.
    Neck: Normal range of motion. Neck supple.
    Cardiovascular: Regular rhythm, S1 normal and S2 normal.
    Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.
    Abdominal: Soft. She exhibits no distension. No tenderness. She has no guarding.
    Musculoskeletal: Normal range of motion.
    Neurological: She is alert.
    Skin: Skin is warm and dry.

    Assessment and Plan: Well child check
    Immunization need

    Varicella, flu and Hep A vaccine

    Shouldn't this be a preventive visit not a problem focused visit for one? and Then dx for 90658 should be V0481
    Also shouldn't V70.0 be for preventative visits not problem focused?
    Please let me know what your thoughts are.

  2. #2
    Columbia, MO
    I am agreeing with you 100%

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Thank you I apperciate the feed back.

  4. #4
    Default Preventative
    I concur as well!
    Becky Stephenson, RN, CPC, CPC-H
    President/CEO VersaClaim, Inc.
    Austin, Texas

  5. #5
    Don't forget to add your admin codes!!

  6. Default
    This may be to late but i'd bill
    dx V20.2 cpt 9938X depending on child's age new pt..

    dx V20.2 is child 17 or under dx V70.0 is for adult

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