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Preventive/New Patient

  1. #1
    Default Preventive/New Patient
    Medical Coding Books
    CC-New patient to establish,referral for mammogram.
    HPI-Pt is a 62 yr old female. New establish care. HTN/High chol/patient on Weight Wathcers. Pt having breast pain on the rt side, last mammogram was 2 yrs agao. last labs 6 months ago. pt wants Wellness visit.
    Past Medical/Surgical Hx
    Reported Hx:
    Pregnancy: Gravida 2
    Diagnosis HX:
    Therapeutic Hx:
    Social Hx:
    Behavioral: Caffeine use 2 cups of coffee daily. Not smoking. A previous hx of smoking quit 6 yrs ago.
    Alcohol: Alcohol use socially
    Drug Use: Not using drugs
    Habits: Good exercise habits
    Work: retires
    matial: Currently married
    Functional: No physical disability
    Cariovascular: No symptoms
    Pulmonary: No symptoms
    GI: No symptoms.
    Pertinebt positives and negatives as stated in the HPI; otherwise negative in all 14 systems as reviewed with the patient.
    Physical Findings:
    Heneral Appearance:
    Oriented to time, place ad person in no acute distress.
    Suppleness: The nek demonstrated no decrease in suppleness.
    Thyroid: The thyroid showed no abnormalities.
    Normal breath sounds/voice sounds, no wheezing was heard, no rhonchi were heard, and no rales/crackles were heard.
    Heart Rate and Rhythm: Heasrt rate and rhythm normal
    Heart Sounds: S1 nomral and the S2 was normal
    No murmurs were heard.
    Edema not present.
    Speech was normal
    Gait and Stance were normal.
    Psych: Affect was normal
    Skin: Skin temperature was normal.
    Pain in Rt breast-Possible M/S as pt started exercise and diet program.
    last mamogram was 2 yrs ago
    Normal routine Hx and Physical
    Essential Hypertension-last labs was 6 months ago. Ordered. Atenolo/HCTZ 50/25 g q day request 90 days refill
    Hyperlipidema-labs orderd Lovastatin 20 mg Q eve. refilled per pt request
    Mammogram ordered. labs ordered
    Dx HTN/High Chol
    OK, after all of that my question is; would you code this as a Preventive or New Patient. My provider did both. I don't feel this is correct. Thanks for your help as always.

  2. Default
    I believe it would fall under the 99386, which is new patient preventive medicine.

  3. #3
    I would have the V70.0 code moved to the priamry diagnosis, since it is a primary diagnosis only and for the E&M I would code the 99386 along with 99201 with modifier 25 to say the doctor went above and beyond the preventative medicine visit with an acute symptom such as the breast pain. I counted the chronic conditions as part of the wellness visit. Hope this helps.

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