Wiki is this counseling risk factor or an office visit?

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ollielooya

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Patient had a visit the previous day for a fall at a gymn which resulted being seen for a headache. After seeing the dr and being advised to go to the ER, now the patient is back the next day for another problem. The prior visit that sent him to the ER is only mentioned. The rest of subsequent visit is based on consultation for STD prevention. Other than general vital signs and psych, no additional examination occurred.. Should this visit be coded to the 994xx series or would the regularly 9921X be appropriate? The Counseling Risk Factor Reduction seems more specific and applicable to this situation in my mind. I'm also concerned about the V code. Wouldn't another be more applicable and specific to this visit rather than a V70.0?

I can provide chart note if it would be helpful.
 
Hi, Marcus, thank you for the excellent guideline. This particular patient is an adult and not sure if this would be applicable in this case? If the visit is for STD counseling and it seems like the 9640X codes would be the best bet, why would the E&M codes be a better choice? I'm just puzzled by all of this. Dr doesn't mention anything about the visit for the injury the day before where patient was advised to go to ER. Just comments to the fact that patient did so in fact. So, even with all this the E/M seems the way to go?
 
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