Results 1 to 3 of 3

E/M vs. Preventative Family Planning Visit

  1. #1
    Default E/M vs. Preventative Family Planning Visit
    Medical Coding Books
    How would you code this visit? E/M or Preventative. If Preventative, can I get away with coding an additional E/M based on evaluation of patient for insomnia and subsequent prescription? Insomnia is has been a problem since visit the year before. The lack of HPI and ROS is what bothers me about coding the visit. No Comprehensive History component.


    CC: Annual PE and Pt would like referral for Vasectomy
    HPI: Wife wants to go off pill. Interested in birth Control
    PMH: Lumbar Disc Disease
    Surg Hx: 0
    Allergies: NKDA
    Social H: Married, No tobacco use, alcohol socially
    ROS: sleep problems
    Vitals Documented
    Exam:
    General: Normal
    Head: Normal
    Eyes: Normal
    Neck: Normal
    Chest: Normal
    Breasts: Normal
    CV: Normal
    Abdomen: Normal
    Back: Full ROM, non tender
    Ext: Normal
    Skin: Normal
    Neuro: Normal
    Assessment: Family Planning, Insomnia, Lumbar Disc Disease
    Plan: Urology Consult, Lunesta RX


    Thanks for your input.
    Heather Winters, CPC, CFPC

  2. #2
    Default
    the lack of info bothers me, too lol lol
    okay it's only a preventative....there has to be an HPI/EXAM/MDM of the pertinent problem (s)....looks like this MD referred pt to URO to handle the vasectomy...don't see any mention of insomnia

    Quote Originally Posted by heatherwinters View Post
    How would you code this visit? E/M or Preventative. If Preventative, can I get away with coding an additional E/M based on evaluation of patient for insomnia and subsequent prescription? Insomnia is has been a problem since visit the year before. The lack of HPI and ROS is what bothers me about coding the visit. No Comprehensive History component.


    CC: Annual PE and Pt would like referral for Vasectomy
    HPI: Wife wants to go off pill. Interested in birth Control
    PMH: Lumbar Disc Disease
    Surg Hx: 0
    Allergies: NKDA
    Social H: Married, No tobacco use, alcohol socially
    ROS: sleep problems
    Vitals Documented
    Exam:
    General: Normal
    Head: Normal
    Eyes: Normal
    Neck: Normal
    Chest: Normal
    Breasts: Normal
    CV: Normal
    Abdomen: Normal
    Back: Full ROM, non tender
    Ext: Normal
    Skin: Normal
    Neuro: Normal
    Assessment: Family Planning, Insomnia, Lumbar Disc Disease
    Plan: Urology Consult, Lunesta RX


    Thanks for your input.
    Rachele Porter, AS, CPC, CPC-H, CEDC
    no weapons formed against me shall prosper

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Too Bad there's No Time noted
    If time spent w/ the patient had been noted, along with a statement that more than 50% of that time was in counselling/coordination of care you could bill the E&M services based on time.
    F Tessa Bartels, CPC

Similar Threads

  1. Family Planning MCD Help!!
    By adaniel in forum Family Practice
    Replies: 2
    Last Post: 08-13-2014, 07:38 PM
  2. Family planning modifer
    By sabarinath in forum Modifiers
    Replies: 2
    Last Post: 06-11-2012, 09:15 PM
  3. Family planning
    By gnp001 in forum Family Practice
    Replies: 0
    Last Post: 09-16-2010, 11:49 AM
  4. Family Planning during postpartum visit
    By 01083047 in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-24-2010, 09:59 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?

Login

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.