Wiki No qualifying visit?

[Greenpiper]

Provider is wanting a 99202 for this visit. I do not feel this visit has enough documentation for a qualifying visit. Does anyone see something I may be missing? Thank you

Primary Care Provider:
Accompanied by: Self
Visit Type: New Visit

Chief Complaint: Estab care- Requesting labs

History of Present Illness:
30 Years Old Male here today. to establish care. States he is healthy and well. States he receaved blood work from his work for insurance but theyt did not run a glucose check which he needs. Is requesting this. Lipids ok. No other s,x questions or concerns.

Problem List Changes:
Added new problem of Preventive health care (ICD-V70.0) (ICD10-Z00.00)
Assessed Preventive health care as new

Review of Systems:
General: Denies fever, chills.

Vital Signs:
Weight: 219.12 lbs. (99.60 Kg.) Height: 74 in. (187.96 cm.) BMI: 28.24 O2 Sat: 98 On: Room air Pulse: 72 Pulse Rhythm: Regular
Blood Pressure #1: 120/82 mm Hg. Location: Lt Arm Position: sitting
Entered by: August 3, 2020 8:04 AM

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Neurologic: neurologically intact
Psych: Alert and oriented.

Assessment and Plan:
• PREVENTIVE HEALTH CARE (ICD-V70.0) (ICD10-Z00.00) New
Healthy and well. Will send for labs. WIll call with results. Previous labs reviewed and discussed. See back PRN.

Orders:
Basic Metabolic Panel [BMP]
New Level 2: Brief [CPT-99202]

Portions of this report may have been transcribed using voice recognition software. Every effort was made to ensure accuracy; however, inadvertent computerized transcription errors may be present.

 

[thomas7331]

This is a preventive visit, so the appropriate code would be 99385. 99202 requires a problem/chief complaint, which is not documented here. Establishing care and requesting labs are not a medical problems that require an E&M service.

 

[Greenpiper]

According to CPT, the comprehensive history that must be obtained as part of a preventive visit has no chief complaint or present illness as its focus. It requires a “comprehensive system review and comprehensive or interval past, family, and social history along with a comprehensive assessment/history of pertinent risk factors.”

I'm not seeing any PFSH or Comprehensive ROS so do not feel this meets Preventive requirements either. Maybe I'm overthinking this. Trying to get some documented feed back for provider education. Which soon will be a mute point but this is something we are still struggling with at this time.

 

[thomas7331]

According to CPT, the comprehensive history that must be obtained as part of a preventive visit has no chief complaint or present illness as its focus. It requires a “comprehensive system review and comprehensive or interval past, family, and social history along with a comprehensive assessment/history of pertinent risk factors.”

I'm not seeing any PFSH or Comprehensive ROS so do not feel this meets Preventive requirements either. Maybe I'm overthinking this. Trying to get some documented feed back for provider education. Which soon will be a mute point but this is something we are still struggling with at this time.

Actually, see the note in CPT under preventive medicine services - a comprehensive history and exam, in the sense in which this term is using in E&M leveling, is not required for preventive services:

The "comprehensive" nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is NOT synonymous with the "comprehensive" examination required in Evaluation and Management codes 99201-99350.

But I tend to agree with you, even considering this, that the provider hasn't really done a comprehensive service. Visits done to 'establish care' are always problematic. I've found it best to tell providers and clinical staff to avoid this completely.