We had a young patient from out of the area come here with her mom just to establish care. I know that the CPT code is a regular office visit but I can't figure out what to bill for the DX code as the patient didn't have a pelvic exam or pap smear. I'm at a loss of how to code this. Can someone help me?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Establish Care DX Code
- Thread starter kenkie79
- Start date
Pam Warren
True Blue
If there's no chief complaint, then you wouldn't code a problem visit. You'd code a preventive visit.
We caution our providers with regards to this. Often patients want a meet & greet. That's not medically necessary according to the payers.
We caution our providers with regards to this. Often patients want a meet & greet. That's not medically necessary according to the payers.
Mcsalazar00
New
- Messages
- 4
- Best answers
- 0
So if there is no cheif complaint then this is not billable. provider is billing a 99212 with z71.89
thomas7331
Guest
Per the guidelines, a chief complaint can be simply a medically necessary reason for the visit documented by the provider - it doesn't necessarily have to be an actual 'complaint' by the patient. But the provider does have to document why the E/M service is being done. If it is missing or unclear, then I'd probably query the provider for additional information rather than making it 'not billable'.
Chief Complaint (CC)
A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.