Wiki E&M coding - please help

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LanaW

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I am trying to do my first E&M audit - one of my providers saw a new patient to establish and he did an office note which states NEW PATIENT HERE TO ESTABLISH...........
He did a short history.......
He also stated - "Pap not due until July - come in then"
and
he did speak with her regarding conception plans, LMP, vitals and BMI - this is all documented with an office note.
He also no charged her since he did not do a full exam....my questions is - when she comes back in is she now established or new?

Thanks!
 
E & M coding

I would look and see if this was booked as a meet and greet appointment. We allow a 15 min appt. In our practices there are no exams done,just a face to face meet. No rx's, labs, xrays or any other tests are ordered. Hope this helps.
 
The patient encountered and presented to the clinic with a situation requiring the providers cognitive labor through coordination plans, LMP, vitals, BMI and a planned encounter down the road, which is less than three years, they would be established for the second visit and new for the first.

Not 100% sure about this!:confused:
 
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