Hello all, what diagnosis do you use for a new patient without any issues/concerns is seen specifically to establish care. We're a family practice. Can dx Z76.89 be used or is it acceptable as a primary diagnosis?
If documented correctly, Z00.00 would be appropriate. Insurance plans requiring the patient to list a PCP could be a driving force for the visit. If this is the case, document as the reason for the encounter. If the patient is new to the area and wanted to establish a rapport with a PCP, document this as the reason for the encounter. I assume the patient completed a medical history form. History codes as secondary codes would help support medical necessity. Hopefully an exam was done to establish baseline information. Were medications, if any, documented or is there documentation that the patient is not taking any medications? Is your doc going to take over any medication management? Did the patient provide past medical records for review? It all boils down to what was done and how well it was documented. If they just did a chit chat and a handshake, then your doc worked for free.Hello all, what diagnosis do you use for a new patient without any issues/concerns is seen specifically to establish care. We're a family practice. Can dx Z76.89 be used or is it acceptable as a primary diagnosis?