# Establishing Care as a Chief Complaint



## sbrown64 (May 8, 2009)

My thought is if a patient presents to establish care, even with pre-existing problems, this is a preventative enounter, not a new problem unless the physciains or NPP is treating the problems.

Example:

Patient presents to estalish care, being transferred from Dr. X. 

Hx: Patient has history of HTN, DMII and is significant for chronis renal failure. Recently established care with Dr Y. in nephrology. Patient has microscopic hematuria, horsehoe kidney, 1.7 cm left pelvic stone, goput and cyst to his right groin. No current concerns.

The exam is comprehensive
An EKG was performed (no medical necessity other than prev med). No complaints documented.
Patient to return in 3 months to begin B12 injections. He was given literature regarding his HTN. 
No meds or other tests were performed.

Thoughts? Please provide cites if you have them.  Thanks again!

Thanks - Schawn Pedersen, CPC, CEMC


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## FTessaBartels (May 8, 2009)

*Preventive Exam*

From the info given, I agree, it's a preventive medicine exam.

F Tessa Bartels, CPC, CEMC


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