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Well visit and infertility discussion

  1. Default Well visit and infertility discussion
    Medical Coding Books
    Hello All,
    Would like to know if you agree with billing both preventive code and EM for discussion of infertility.
    Any thoughts would be greatly appreciated! Thank you.
    See below:

    Allergies: No Known Allergies.
    Vital Signs
    Entered weight: 98 lb., 6 oz.
    Calculated Weight: 98.38 lb. (44.72 kg.)
    Height: 63 in. (160.02 cm.)
    Body Mass Index: 17.49
    Body Surface Area (m2): 1.43
    Blood Pressure: 98/66 mm Hg

    Urinalysis (dipstick)
    Protein: neg; Glucose: neg mg/dl;

    LMP: 01/17/2011
    Last Pap: WNL (02/19/2010 9:39:55 AM)
    Age 1st Menses: 14
    Frequency: 42
    Duration: 5
    Hx of Abnormal Pap: No

    Chief Complaint: Annual exam
    History of Present Illness:
    The patient presents for an annual exam.The patient states that she is sexually active with one partner., The patient denies a history of STD's., The patient reports that her last pap smear was normal.The patient reports that she is currently using nothing for contraception.
    Patient reports irregular menstrual cycles. Stopped breastfeeding 7/2010. Has a history of irregular cycles q48-62 days. Planning to start trying to conceive.

    Pregnancy History
    Total Preg.: 3
    Full Term: 1
    Premature: 0
    Ab. Induced: 0
    Ab. Spontaneous: 2
    Ectopics: 0
    Multiple Births: 0
    Living: 1

    Pregnancy #1
    Delivery date: 05/23/2008
    Comments/Complications: Spont AB

    Pregnancy #2
    Delivery date: 01/12/2009
    Comments/Complications: spont ab

    Pregnancy #3
    Delivery date: 01/03/2010
    Type of anesthesia: epidural
    Delivery type: NSVD
    Birth weight: 7-0
    Sex: Male
    Baby's Name: CARTER
    Delivery location: WPH
    Comments/Complications: MA- VIACORD collection. spont labor. baby devel neonatal mastitis- on augmentin.

    Past Medical, Family, and Social History

    Past Medical History (reviewed - no changes required): Herpes simplex Virus- Type 1

    Past Surgical History: D & C - 5/23/08, 1/12/2009 due to spont ab; chromsomes 69XXX for first; 46XY for second
    IUI - 4/12/2009

    Family History (reviewed - no changes required): Basal Cell Ca-F

    Social History: Dentist- madison Ave
    Graduate School

    Review of Systems
    General: negative
    Eyes: negative
    Ears/Nose/Throat: negative
    Cardiovascular: negative
    Respiratory: negative
    Breast: negative
    Gastrointestinal: negative
    Genitourinary: negative
    Sexuality: negative
    Musculoskeletal: negative
    Skin: negative
    Neurologic: negative
    Psychiatric: negative
    Endocrine: negative
    Heme/lymphatic: negative
    Allergic/Immunologic: negative

    Physical Exam
    Appearance: well developed, well nourished, in no acute distress

    Head exam: normocephalic and atraumatic

    Thyroid: no nodules, masses, tenderness, or enlargement
    Breast exam: nontender, no masses or nipple discharge
    Abdomen: soft, nontender, nondistended, no masses
    Skin: intact without lesions or rashes
    Lymph: normal
    Extremities: no clubbing, cyanosis, edema, or deformity

    Genitourinary Exam
    Vulva: normal appearance, normal hair distribution, and no lesions or masses
    Urethral meatus: normal
    Urethra: no discharge
    Bladder: no cystocele
    Support: normal
    Vagina: normal appearing without lesions or discharge
    Cervix: normal appearance; no lesions or discharge
    Uterus: normal size and position; no masses
    Adnexa: no masses or tenderness
    Rectal exam: normal
    PAP done

    Impression & Recommendations:

    Pap smear done
    Breast and pelvic exam wnl
    Encouraged self breast exams
    Return to office in 1 year for routine annual exam

    Estab Phy 18-39 (99395)

    Problem # 2: INFERTILITY, ANOVULATORY (ICD-628.0)
    Patient with known anovulatory infertility, but has become pregnant spontaneously
    Patient's cycles still irregular
    Interested in conceiving in the near future
    Discussed options of expectant management for 6-12 months vs. starting again with REI group to have cycles monitored
    Recommended that patient continue prenatal vitamins for now -- prescription given
    Referred patient to REI in NC as patient feels this may be more convenient for her given her work schedule

    Spent ~15 minutes discussing this issue
    Ofc Vst, Est Level 3 (99213)

    PAP Screening:
    Last PAP smear: 02/19/2010
    Reviewed PAP smear recommendations: PAP smear done

    Osteoporosis Risk Assessment:

    Risk Factors for Fracture or Low Bone Density:
    Smoking status: never

    Immunization & Chemoprophylaxis:
    Influenza vaccine: DONE (10/01/2009)

  2. #2
    I agree with you to bill for the annual well woman and discussion for infertility. Just not sure if I would code for a level 3 compared to a level 2. Reason being that patient was recommended to start prenatal vitamins and is referred to another specialist for infertility in depth.

    The WWE is a very thorough note.
    The Oracle

  3. Default
    Hey I agree. Looks about right and I also think 99212 might be the right way to go.

    I do have a question thats related to this issue:

    Lets assume this is a new ptn. First time in the office and everything else is more or less the same. Would BOTH codes change to new or just one of them. (99385 to 99395 and 99212 to 99202). ?????

    I have all carriers across the board paying for 99385 and 99203 (for example) and Only one carrier telling me (after former appeal) that "once the ptn has been seen for annual the E &M can be considered as" new". So one the codes will be denied for "New Ptn frequency visit error."

    Can you guys please explain whats would be right way to go about this.


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