Wiki New Patient Dx code advice

[jhendrix08]

In the case where a new patient comes in to establish care in our office (PCP), I have had some denials when the providers use Dx Z76.89 I had a couple denials stating not a covered expense and others stating not covered when considered routine due to the use of the Z code.

Say in the case that the patient is otherwise healthy (young) and has no acute or chronic conditions and is coming in for the sole purpose to establish care with a new PCP, can anyone shed some light on a better Dx code to use if we have nothing else to use?

I really appreciate any advice! Thanks!

 

[lefevrec]

Are you billing an office visit or a routine physical? Is the patient eligible for a routine visit?
I think it all depends on the patient's insurance. If they are eligible for a well visit and came in with no issues for a routine exam, then I would use Z00.00 or Z00.129 depending on their age.
Now, if the patient has no coverage for well visits, then they ultimately are responsible for the cost because they were not concerned about or treated for any ailments.

 

[jhendrix08]

We schedule our new patients as a 30 min new patient establish care appointment, not a routine physical exam. So, I wouldn't be able to code the physical exam Z codes. Thoughts?

Thanks so much for replying!!

 

[thomas7331]

There is no appropriate way to code for a visit to 'establish care' - this term does not have any definite meaning in terms of a medical service and there is no CPT code to represent this, and you can only choose your code based on the service rendered. If the purpose of the new visit is for the provider to take over management of the treatment for a patient's ongoing problems or chronic conditions, then this can be appropriately with a new or established patient E&M code. If the patient has no problems, and they are not performing a routine exam or other preventive service, then there is no medical necessity to support an E&M service. Simply bringing in a patient in for a separate visit just to meet with the provider and build a medical record is not necessary and would likely be seen by an auditor as only a convenience for the patient and/or the provider. This is not a separate covered service under most plan benefits and in my opinion is not appropriate thing to bill to a medical insurance payer. In the practices I've worked with, if the provider did not document a defined preventive or medically necessary service in the record, we made these a no-charge visit.

 

[jhendrix08]

Thank you for clarifying this for me. I appreciate the input and will discuss with my providers.