Wiki Establishing Care - new pt exam

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calexander1265

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Our Pediatrician had a child 3 years old, brought in to see doctor to establish with the practice. Unfortunately the child would not allow a complete exam, so doctor was not able to charge for a new patient exam. Another coder has said that if the doctor dictated the patient would not allow exam and named the body area's he tried to examine and could not due to uncooperative patient, then he can count these toward exam. I have never heard of this, but I have never coded for pediatrics. Any feedback would be appreciated.
 
pediatric exam

calexander1265 said:
Our Pediatrician had a child 3 years old, brought in to see doctor to establish with the practice. Unfortunately the child would not allow a complete exam, so doctor was not able to charge for a new patient exam. Another coder has said that if the doctor dictated the patient would not allow exam and named the body area's he tried to examine and could not due to uncooperative patient, then he can count these toward exam. I have never heard of this, but I have never coded for pediatrics. Any feedback would be appreciated.
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Any thoughts on this question??
 
Cheryl, if this was a preventive visit (no complaints of illness, signs, symptom, etc.), and the patient meets the CPT definition of a new patient, then the encounter should be reported as code 99382, Initial Comprehensive Preventive Medicine...new patient, early childhood (age 1 through 4 years)

The preventive medicine series of codes are reported by patient age, rather than E/M components. However, it's still a good idea for the physician to document history, exam, etc., and include the fact that the patient was uncooperative for the exam.

If this visit was a new patient sick visit, the key E/M elements (or counseling and coordination of care time) performed would determine the visit level.

The only circumstance that I'm aware of regarding allowance for exam components not performed is the critical life-saving ED situation. There may be other situations that I'm not aware of.

Hope this helps,
Jettman
 
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