Wiki Establish care/no exam

[arrana]

Hi,

We have a new patient who came in to establish care. While in the office he requested STD testing, but has no specific concerns. He also received a Tdap vaccine while in the office. The provider, a PA, coded with dx 994.9, exposure, and a 99202 e/m code, in addition to the correct vaccine codes. We believe that with this dx insurance likely won't pay the visit, but there was no medical complaint, the primary reason was to establish care. What do you recommend as the best way to code this to get reimbursed?

Thanks,
Arrana

 

[MnTwins29]

Procedures/vaccines only, no E & M

Even though the patient was exposed, this sounds like he only came for the test and vaccinations. Code and bill for the procedures and vaccines you provided, but there is no E & M level you can use. Especially if there is no exam and this is a new patient, since you need all 3 key elements. As for "establishing care" - by presenting and recieving services at your office, the patient is now established - it doesn't have to be a preventive med visit or sick visit in order to do so.

 

[mitchellde]

If an exposure is not documented then you cannot use the code. 994.9 is an injury cause.. indicating other effects of an external cause such as lightening etc, not sexual contact. an exposure code would be a V01.x code, but if none is documented and the patient just wants one, then use a screening V code, the patient may be liable for the charge of the lab test, you should have explained this to him.
You cannot use dx codes that the documentation does not support, from what you have related there is nothing to support the use of the 994.9 code.