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jmeberst314@gmail.com

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What diagnosis should I use for new patients that are just wanting to establish with the practice but have nothing wrong with them? ie; 19 year old male, healthy, no history of previous illnesses, no meds and didn't have time to do a physical. Just wanted to establish with the office.
 
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Out of curiosity...

jlobianco03@gmail.com said:
What diagnosis should I use for new patients that are just wanting to establish with the practice but have nothing wrong with them? ie; 19 year old male, healthy, no history of previous illnesses, no meds and didn't have time to do a physical. Just wanted to establish with the office.
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What CPT code did you use? This topic always sparks various opinions...
 
diagnosis

Report V70.0 for routine general medical examination at a health care facility. Unless counseling was provided, then report V65.40.
 
makasprzyk said:
Report V70.0 for routine general medical examination at a health care facility. Unless counseling was provided, then report V65.40.
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But...the poster stated that a physicial wasn't provided. Reporting V70.0 could compromise a future physical exam. V65.40 could work (assuming counseling was actually provided) but I would really like to know what CPT code was reported. Depending on the answer, there could be "issues" with the code selection. If insurance is involved...well...that potentially opens another "can of worms".
 
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An exam was not performed so there is not a Dx code or E/M code that can be used, I do not think there is anything that can be billed. A person can not become an established patient until meeting criteria for a new by receiving professional service from physician. I'd be very leary of using unlisted E/M services code.
 
tnmacs@comcast.net said:
An exam was not performed so there is not a Dx code or E/M code that can be used, I do not think there is anything that can be billed. A person can not become an established patient until meeting criteria for a new by receiving professional service from physician. I'd be very leary of using unlisted E/M services code.
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Now...we're on track...
 
We have an internal code Meet & Greet. No other services are done. This does not go to an ins company. Dx code V65.49. Basically, the Pt interviews the Provider to see if this will work for their needs.
 
CPT code we were going to use was a 99202-99201; constitutional ROS (ie. problems w/sleep, energy appetite, bowel movement, etc.), family history, social history, no know allergies/meds, vitals. A general exam, ie. oral cavity, thyroid, chest, heart & lungs, and abdomen checked. This was all done during his visit, it is straightforward mdm, but it is an office visit.
If I were to use V70.0 would I be able to use it again later in the year when he comes in for his wellness visit?
 
Any time documented? - maybe X minutes of counseling i.e. discussing healthy options, even if they amount to nothing more than "keep doing what you're doing"? As for ICD-9, if this is an option to get a 9920x, then use V65.49.
 
jlobianco03@gmail.com said:
CPT code we were going to use was a 99202-99201; constitutional ROS (ie. problems w/sleep, energy appetite, bowel movement, etc.), family history, social history, no know allergies/meds, vitals. A general exam, ie. oral cavity, thyroid, chest, heart & lungs, and abdomen checked. This was all done during his visit, it is straightforward mdm, but it is an office visit.
If I were to use V70.0 would I be able to use it again later in the year when he comes in for his wellness visit?
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I would report V65.49 and not V70.0. This would likely compromise the patient's future physical for this year. I hope the patient was informed that he will likely be responsible for the bill. That could be the end of patient and doctor relationship...lack of communication; although, the patient does have a responsibility to know his/her benefits. Just a thought...
 
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