Wiki Meet and greet?

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ertennal

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Hi there. Wanted to know the opinions of some of my peers about the following chart note and how to code. What are your thoughts?

HPI: Establish Care. No other concern today. Has had flu shot.

Pt is here to establish care today. She is transferring care from another of our clinics. She denies any specific questions or concerns today.

Pt reports overall she has been fairly healthy. She had a hip surgery earlier in the year. Unfortunately, she fracture her wrist this year. Being treated for osteoporosis.

Patient states she is likely due for mammogram. She states it has been about 2 years since her last assessment. I do not see record on file.

Patient states that she has a 7 yr old daughter and a 9 yr old daughter. She reports both girls keep her very active and healthy. She has never smoked, is retired and Married. Does not use alcohol or recreational drugs.

ROS was extended
PE was expanded problem focused

Impression and recommendation:
Osteoporosis, patient is to continue treatment, when able increase weight bearing exercise.

Screening mammogram ordered.

Should this be billed out? Being an established patient from one of our other clinics, new to this provider, with no complaints. Yes, mammogram was ordered. No mention of followup.
 
OK - for established, you need 2 of 3. I would call this a 99212. However, my main reserve is CC. It just says pt is here to establish care, without saying why. If it said "pt is here to establish care for osteoporosis", I would not hesitate. Just like the CC can't be "follow up" without stating follow up for what or "review test results" without having problem/signs/symptoms.
Exam is noted as expanded problem focused. MDM is straightforward - orders a radiology test & notes osteoporosis treatment.
Soooo, I would stretch it to 99212 & educate my provider about chief complaint. I would also wonder why the patient bothered to come in for an appointment if she doesn't have any questions or concerns.
 
Very well said Christine, I agree 100%. Insurance companies pay benefits for provider to treat patients' medical problems, and none that I know of offer a benefit for a 'meet and greet'. The providers and medical staff should be educated to document the medical necessity of the services they are performing if they wish to bill these under the patients' medical benefits. At the last practice I work, this actually became such a problem over time that the office manager finally put her foot down with the providers and told them that if they documented that a visit was to 'establish care' or for a 'meet and greet', that was fine, but they wouldn't be billing or getting paid for it.
 
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