# New patient dx?



## veloso (Nov 5, 2010)

Hello Everyone,
  I have a New Patient with a Chest Pain (99203) but the Provider order labs. (LIPID PANEL) for a Routine V70.0.
QUESTION#1.
 It is okey to bill 99203 =PRI.DX.-CHEST PAIN AND SEC.DX.-V70.0 
AND BILL FOR 36415-FOR V70.0. 

QUESTION #2.
Do you think this will not get rejected since the patient chief complaint does not include a PREVENTIVE VISIT?

THANK YOU ALL...


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## mitchellde (Nov 5, 2010)

no you cannot do this.  The V70.0 is first list only allowed for one and from what you have stated this was not a preventive encounter at all.  The question is then why did he order the lipid panel, is it for screening? then use a screening V code, or is it because the patient is taking a medication then it would be the V58.83 with the V58.6x code with your chest pain first listed.


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## veloso (Nov 5, 2010)

Hi Mitchell,
  Here it the LABS that was ordered maybe you could help ME for the specific DX's for the following TESTS and THANKS A LOT for YOUR kind attention for my QUERY..

Treatment:
    1.Chest pain, unspecified
        Start Omeprazole Capsule Delayed Release, 40 mg, Orally, 30, 1 capsule, Once a day, 30 day(s), Refills 3
         Lab:LIPID PANEL  Result Status : F                HDL CHOLESTEROL 59 >=46 - mg/dL N 
                CHOLESTEROL,TOTAL 215 125-200 - mg/dL H 
                TRIGLYCERIDES 75 <150 - mg/dL N 
                LDL CHOL, CALCULATED 141 <130 - mg/dL H 
                CHOLESTEROL/HDL RATIO 3.6 < = 5.0 - N 
         Lab:CARDIO CRP  Result Status : F                CARDIO CRP 1.8 - mg/L N 
         Lab:THY PNL/TSH/FT4  Result Status : F                TSH,3RD GENERATION 2.22 0.40-4.50 - mIU/L N 


    2.V70.0=ROUTINE MEDICAL EXAM
         Lab:COMP METAB PANEL W/EGFR  Result Status : F                ALT 16 6-40 - U/L N 
                ALBUMIN 4.5 3.6-5.1 - g/dL N 
                A/G RATIO 1.4 1.0-2.1 - N 
                AST 20 10-30 - U/L N 
                BILIRUBIN,TOTAL 0.4 0.2-1.2 - mg/dL N 
                CALCIUM 9.5 8.6-10.2 - mg/dL N 
                CARBON DIOXIDE 22 21-33 - mmol/L N 
                CHLORIDE 104 98-110 - mmol/L N 
                CREATININE 0.74 0.57-1.03 - mg/dL N 
                GLOBULIN,CALCULATED 3.3 2.2-3.9 - g/dL N 
                POTASSIUM 4.2 3.5-5.3 - mmol/L N 
                PROTEIN,TOTAL 7.8 6.2-8.3 - g/dL N 
                SODIUM 137 135-146 - mmol/L N 
                EGFR NON AFR AMERICAN >60 >=60 - mL/min/1.73m2 N 
                EGFR AFRICAN AMERICAN >60 >=60 - mL/min/1.73m2 N 
                GLUCOSE 87 65-139 - mg/dL N 
                UREA NITROGEN 8 7-25 - mg/dL N 
                BUN/CREATININE RATIO NOTE 6-22 - N 
                ALKALINE PHOSPHATASE 48 33-115 - U/L N 
         Lab:LIPID PANEL  Result Status : F                HDL CHOLESTEROL 59 >=46 - mg/dL N 
                CHOLESTEROL,TOTAL 215 125-200 - mg/dL H 
                TRIGLYCERIDES 75 <150 - mg/dL N 
                LDL CHOL, CALCULATED 141 <130 - mg/dL H 
                CHOLESTEROL/HDL RATIO 3.6 < = 5.0 - N 
         Lab: CBC (INCLUDES DIFF/PLT)  Result Status : F                DIFFERENTIAL An instrument differential was performed. - N 
                HEMATOCRIT 37.9 35.0-45.0 - % N 
                MONOCYTES,% 3.4 0-13 - % N 
                WBC 7.4 3.8-10.8 - Thous/mcL N 
                BASOPHILS,ABSOLUTE 22 0-200 - Cells/mcL N 
                BASOPHILS,% 0.3 0-2 - % N 
                EOSINOPHILS,ABSOLUTE 126 15-550 - Cells/mcL N 
                EOSINOPHILS,% 1.7 0-8 - % N 
                HEMOGLOBIN 12.8 11.7-15.5 - g/dL N 
                LYMPHOCYTES,ABSOLUTE 2316 850-3900 - Cells/mcL N 
                TOTAL LYMPHOCYTES,% 31.3 15-49 - % N 
                MONOCYTES,ABSOLUTE 252 200-950 - Cells/mcL N 
                NEUTROPHILS,ABSOLUTE 4684 1500-7800 - Cells/mcL N 
                TOTAL NEUTROPHILS,% 63.3 38-80 - % N 
                MPV 9.4 7.5-11.5 - fL N 
                PLATELET COUNT 222 140-400 - Thous/mcL N 
                MCH 27.9 27.0-33.0 - pg N 
                MCHC 33.8 32.0-36.0 - g/dL N 
                MCV 82.4 80.0-100.0 - fL N 
                RDW 13.8 11.0-15.0 - % N 
                RBC 4.60 3.80-5.10 - Mill/mcL N


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## mitchellde (Nov 5, 2010)

this looks like results from labs ordered at a previous vist??   I am not sure where the routine wellness visit fits in .  It just seems a bit out of step to have a patient with a chief complaint of chest pain and we perform a wellness vist in the same setting.  From what you have posted here I see lab results not an order for labs.


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## veloso (Nov 8, 2010)

Hi Debra,
  I query the Provider and he told me that he ordered these labs.on this same DOS  as a Routine Lab.because he wants to know the status of patients lipid panel as well.

Thanks again..


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## mitchellde (Nov 8, 2010)

Maybe it is Monday, But I am still not understanding.  He ordered these labs at a previous visit?  when you say the DOS as a routine lab it looks to me like this was ordered at a previous visit.  And what you posted above are the results.  Is he ordering another lipid panel for a new visit with a chief complaint of chest pain?  I am sorry it is just not flowing for me, I apologise.  Can you help me sort it out?


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## veloso (Nov 8, 2010)

Hi Debra,
  I'm very sorry for this inconvenience I'm just trying to be a compliant with the Regualations here it the Progress Notes;

DOS:10/13/10
 Chief Complaint(s):
  midsternal chest pain 

  HPI:   
     General
         Pt came in as a walk-in and will schedule a new appt next time. Her complaint is midsternal chest pain that last 6-8 minutes and comes and goes throughout the day. It happens with activity and at rest. She does not correlate it with happening more often after eating. There is no radiation of the pain. It is associated with nausea ans some SOB. She reports feeling acid in the back of her throat in the morning and feels like gagging. She has not taken anything OTC. She denies being on other meds. She reports drinking lots of coffee throughout the day.
  Current Medication:
  None 

  Medical History:
  Allergies/Intolerance:
  Gyn History:
  OB History:
  Surgical History:
  Hospitalization:
  Family History:
  Social History:
  ROS:


Objective:
  Vitals:
        HR 104, BP 125/80, RR 8, Temp 98.4, Ht 63, Wt 123, BMI 21.79  
  Past Results:
  Examination:   
     General Examination
        GENERAL APPEARANCE: well nourished and hydrated, NAD, comfortable, alert, female, young, pleasant.  HEENT: normal, Head - NC/AT, tympanic membranes normal, eyes normal, EOMI bilaterally, PERRLA, clear conjuctiva, anicteric sclera.  ORAL CAVITY: clear, mucosa moist, normal tongue.  NECK: no thyroid abnormality, no mass, trachea midline.  HEART: no murmurs, regular rate and rhythm,tachycardic.  CHEST: normal shape and expansion, clear to auscultation, symmetrical.  LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales.  ABDOMEN: soft, NT/ND, BS present, no masses palpated, no hepatosplenomegaly.  NEUROLOGIC EXAM: non-focal exam, alert and oriented x 3, CN's II-XII grossly intact, gait normal, normal strength, tone and reflexes, oriented x 3.  Skin: Palpatation of skin and subcutaneous tissue:, Inspection of skin, normal, no rash, no ulcers.  EXTREMITIES: no clubbing, no edema, no cyanosis.  PERIPHERAL PULSES: normal (2+) bilaterally.  LYMPH NODES: normal.  

  Physical Examination:


Assessment:
  Assessment:
  Chest pain, unspecified - 786.50 (Primary) 

  ROUTINE MEDICAL EXAM - V70.0 



Plan:
  Treatment:
    Chest pain, unspecified
        Start Omeprazole Capsule Delayed Release, 40 mg, Orally, 30, 1 capsule, Once a day, 30 day(s), Refills 3
         Lab:LIPID PANEL  Result Status : F                HDL CHOLESTEROL 59 >=46 - mg/dL N 
                CHOLESTEROL,TOTAL 215 125-200 - mg/dL H 
                TRIGLYCERIDES 75 <150 - mg/dL N 
                LDL CHOL, CALCULATED 141 <130 - mg/dL H 
                CHOLESTEROL/HDL RATIO 3.6 < = 5.0 - N 
         Lab:CARDIO CRP  Result Status : F                CARDIO CRP 1.8 - mg/L N 
         Lab:THY PNL/TSH/FT4  Result Status : F                TSH,3RD GENERATION 2.22 0.40-4.50 - mIU/L N 
         I feel pt has atypical chest pain most consistent with GERD. I am concerned about her tachycardia and she reports being anxious. I recommended she stop caffeine and she states that will not be a problem. I also told her if she does not get relief in a few days with omeprazole that she will need cardiology evaluation.
    ROUTINE MEDICAL EXAM
         Lab:COMP METAB PANEL W/EGFR  Result Status : F                ALT 16 6-40 - U/L N 
                ALBUMIN 4.5 3.6-5.1 - g/dL N 
                A/G RATIO 1.4 1.0-2.1 - N 
                AST 20 10-30 - U/L N 
                BILIRUBIN,TOTAL 0.4 0.2-1.2 - mg/dL N 
                CALCIUM 9.5 8.6-10.2 - mg/dL N 
                CARBON DIOXIDE 22 21-33 - mmol/L N 
                CHLORIDE 104 98-110 - mmol/L N 
                CREATININE 0.74 0.57-1.03 - mg/dL N 
                GLOBULIN,CALCULATED 3.3 2.2-3.9 - g/dL N 
                POTASSIUM 4.2 3.5-5.3 - mmol/L N 
                PROTEIN,TOTAL 7.8 6.2-8.3 - g/dL N 
                SODIUM 137 135-146 - mmol/L N 
                EGFR NON AFR AMERICAN >60 >=60 - mL/min/1.73m2 N 
                EGFR AFRICAN AMERICAN >60 >=60 - mL/min/1.73m2 N 
                GLUCOSE 87 65-139 - mg/dL N 
                UREA NITROGEN 8 7-25 - mg/dL N 
                BUN/CREATININE RATIO NOTE 6-22 - N 
                ALKALINE PHOSPHATASE 48 33-115 - U/L N 
         Lab:LIPID PANEL  Result Status : F                HDL CHOLESTEROL 59 >=46 - mg/dL N 
                CHOLESTEROL,TOTAL 215 125-200 - mg/dL H 
                TRIGLYCERIDES 75 <150 - mg/dL N 
                LDL CHOL, CALCULATED 141 <130 - mg/dL H 
                CHOLESTEROL/HDL RATIO 3.6 < = 5.0 - N 
         Lab: CBC (INCLUDES DIFF/PLT)  Result Status : F                DIFFERENTIAL An instrument differential was performed. - N 
                HEMATOCRIT 37.9 35.0-45.0 - % N 
                MONOCYTES,% 3.4 0-13 - % N 
                WBC 7.4 3.8-10.8 - Thous/mcL N 
                BASOPHILS,ABSOLUTE 22 0-200 - Cells/mcL N 
                BASOPHILS,% 0.3 0-2 - % N 
                EOSINOPHILS,ABSOLUTE 126 15-550 - Cells/mcL N 
                EOSINOPHILS,% 1.7 0-8 - % N 
                HEMOGLOBIN 12.8 11.7-15.5 - g/dL N 
                LYMPHOCYTES,ABSOLUTE 2316 850-3900 - Cells/mcL N 
                TOTAL LYMPHOCYTES,% 31.3 15-49 - % N 
                MONOCYTES,ABSOLUTE 252 200-950 - Cells/mcL N 
                NEUTROPHILS,ABSOLUTE 4684 1500-7800 - Cells/mcL N 
                TOTAL NEUTROPHILS,% 63.3 38-80 - % N 
                MPV 9.4 7.5-11.5 - fL N 
                PLATELET COUNT 222 140-400 - Thous/mcL N 
                MCH 27.9 27.0-33.0 - pg N 
                MCHC 33.8 32.0-36.0 - g/dL N 
                MCV 82.4 80.0-100.0 - fL N 
                RDW 13.8 11.0-15.0 - % N 
                RBC 4.60 3.80-5.10 - Mill/mcL N 
  Procedures:
  Immunizations:
  Diagnostic Imaging:
  Lab Reports:
  Preventive Medicine:
  Next Appointment:
  2 Weeks  


Billing Information:
  Visit Code:
  99203 IM Office Visit New Pt Level 3. 1.)DX.786.59 2.)V70.0

  Procedure Codes:
  36415 VENIPUNCT, ROUTINE*. 1.)DX.786.59 2.)DX.V70.0

By the way we do only venipuncture in the clinic and sent to outside laboratory for the results.


THANK YOU VERY MUCH FOR YOUR KIND ATTENTION ON THIS MATTER..GOD BLESS


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## CONSULTA-A-CODER (Nov 11, 2010)

I just wanted to advise you of using V70.0 that diagnosis code is mainly for preventive visit.

Chest pain can stem for many issues!!
It appears to me that you were looking for a diagnosis code to cover the lipid panel and that would be V77.91. This diagnosis code is for screening for lipoid disorder If this is reason for the lipid test.

V5883 is for therapeutic drug monitoring and there is no detection in this this note that patient is on a therapeutic drug. HPI states patient is not on any medication.

I hope this helps!!

CONSULTACODER, BS,CPMA, CPC,CCS


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