Wiki Established Visit

[ladonnaalexis]

Just a quick question. In a case that a patient is returning to the office only for a 1 year follow up and the patient is not having any problems. What would you write for HPI? If you leave HPI blank can you code this as a visit? Im thinking that you can only code this visit only as 99211.

 

[sbicknell]

You didn't say what specialty you are. But what's the CC (chief Compaint)? F/up of what? A chronic conditon?

Then the CC needs to state "pt here for f/up of chronic #1 and chronic #2. The HPI is built around giving a status of these two chronic conditions ie how's the patient doing, any complaints over the last year, current meds, any testing been done etc. The E&M level would be based on HPI/exam/MDM

If you are saying this is just a 1 year annual with no complaints and no chronics and the patient is there just simply because he was told "to come back in a year" then you are looking at a preventive visit