Wiki E/M for Paper Work

[NESmith]

Please help.
CC Complete paper work
HPI: Pt is a pleasant 77-yr old female, who is here to have her paperwork filled out for ALF placement. She denies any acute medical issues at the present time and states she would like to also schedule an annual physicial exam as she has not had one for some time. She states she is ready for being in an ALF and looking forward to her new home. Denies any depression, anxiety about the impending change.
List of Current Medications
List of Allergies
ROS: All other systems negative except those mentioned above in the HPI.
Physical Findings:
Vitals
General: The patient is a well developed, well nourished, in no acute distress
Eyes: No lesions of the lids or bulbar conjunctive: conjuntivae are without erythema. Ocular exam reveals PERRLA, EOMI. Corneas are clear.
ENMT: EACS are clear without erythema or exudates. Good light reflex with no erythema of the TM's. No bulging or retraction. Hearing is intact to normal speech. nasal mucosa is non-congested, without exudates or epistaxis. Teeth are in adequate repair. no lesions of the buccal mucosa. Tongue is midline. Pharynx is nonerythematous, without exudates. Uvula is midline.
Neck: Supple without masses or tenderness. no thyromegaly of JVD.
Cardiovascular: The BMI is non-displaced. S1, S2, regular rate abd rhythm, without audible murmurs. Cartids without bruits. No abdominal bruits heard. Peripheral pulses present in all extrmities. Extremites without edema, varicosities or cyanosis.
Respiratory: There is no retraction. There is no dullness or hyperresonance to percussion. breath sounds are equal and symmetric. There are no rales, rhonchi or wheezes.
Gastrointestinal: Done
Lymphatic-Done
Musculoskeltal-Done
Skin-Done
Neurological-Done
Psychiatric-Done
I did not give the complete detail of all exams. I do believe you got my drift.
Assessment: Routine f/u for AFL placement and paperwork. The paperwork was filled out and signed by provider after interviewing the patient in detail. Pneumovax done at this time.
Please tell me how you would code this and what dx would you use. Thanking You in advance for your help.

 

[melbad]

e/m for paperwork

I don't see "medical necessity" for this visit. I would not bill an E/M visit. Depending on the insurance type, you could bill 99080. "Special reports, such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting forms." But i doubt that would get paid. I would recommend the patient bringing the forms to the office. Then front office staff or management could discuss with patient how the doctor fills out the required report. If an exam is needed, schedule the patient for a wellness visit, charge the preventive medicine code and give the papers to patient then.


The patient has no complaints - so an acute E/M service can't be billed under your scenario.

 

[sgochoco]

Slg

The only thing you could possibly bill is 99080. This is not a sick visit, nor is it a well visit. There has to be a Chief Complaint or "location" of a problem. I would not bill anything for this encounter.