Could someone please help me with the following question? How this problem may be addressed in a practical way;
Internal Medicine specialty providers are billing 99203-99205 for new patient visit that comes for "Establish care" with no abnormality or concerns and providers are putting Z00.00 and Z71.2 with office visits code.
In order to bill sick visit, at least a problem needs to be addressed, lab review or management needs to be performed. How we are going to calculate E/M for such scenarios or what diagnosis needs to be pointer set ?
Example:
Patient presents today as a new patient establishing care with us. She denies taking any medications. She denies any medical conditions. She has an appointment with her gynecologist this afternoon for a pap smear. She has never had a pap smear before. She gets her eyes checked every year because she has poor vision, and she will see her dentist on Wednesday. She has not seen a primary care doctor in a few years, and the last time she was seen was in 2017. Her last menstrual period was from January 10th through the 16th, and she is regular every month. She denies any pain that is unusual during her period. She is sexually active. She notes that she is a little anxious today because she does not like doctor's offices. She denies any nausea, vomiting, bladder problems, or trouble sleeping. She denies any neck pain or blurry vision. She states that she has had intermittent headaches for a few weeks after tripping over a bathtub and hitting her head. She did not see a doctor after the fall but does not think she had a concussion. She denies any pain, drainage, or ringing in her ears. She denies having a sore throat. Her father has a history of diabetes. She notes that her grandmother has recently been in and out of the hospital for thyroid issues and needed to have chemotherapy, but she is not sure what she is. She is currently married. She denies ever smoking or using tobacco products, marijuana, or alcohol. She denies any drug use. She works as an administrative assistant and lab assistant. She has been trying to eat healthier recently and has been cooking at home. She has been exercising at least 5 times per week.
Internal Medicine specialty providers are billing 99203-99205 for new patient visit that comes for "Establish care" with no abnormality or concerns and providers are putting Z00.00 and Z71.2 with office visits code.
In order to bill sick visit, at least a problem needs to be addressed, lab review or management needs to be performed. How we are going to calculate E/M for such scenarios or what diagnosis needs to be pointer set ?
Example:
Patient presents today as a new patient establishing care with us. She denies taking any medications. She denies any medical conditions. She has an appointment with her gynecologist this afternoon for a pap smear. She has never had a pap smear before. She gets her eyes checked every year because she has poor vision, and she will see her dentist on Wednesday. She has not seen a primary care doctor in a few years, and the last time she was seen was in 2017. Her last menstrual period was from January 10th through the 16th, and she is regular every month. She denies any pain that is unusual during her period. She is sexually active. She notes that she is a little anxious today because she does not like doctor's offices. She denies any nausea, vomiting, bladder problems, or trouble sleeping. She denies any neck pain or blurry vision. She states that she has had intermittent headaches for a few weeks after tripping over a bathtub and hitting her head. She did not see a doctor after the fall but does not think she had a concussion. She denies any pain, drainage, or ringing in her ears. She denies having a sore throat. Her father has a history of diabetes. She notes that her grandmother has recently been in and out of the hospital for thyroid issues and needed to have chemotherapy, but she is not sure what she is. She is currently married. She denies ever smoking or using tobacco products, marijuana, or alcohol. She denies any drug use. She works as an administrative assistant and lab assistant. She has been trying to eat healthier recently and has been cooking at home. She has been exercising at least 5 times per week.
