Wiki Patient seen to re-establish???

Rebecca Pate

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Soperton, GA
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I have a patient who turned 65 on 10/31/15. He was seen in the office 11/5/15. Chief complaint states "pt is here to re-establish".
HPI
65 year old white female presents today to reestablish relationship with a significant medical history. She does have Dr ____ for the GYN care. She's active. Dr ___ sees her for paps and mammograms. Pt declines flu vaccine but is amenable to the Prevnar 13. No complaint of nausea, vomiting, fever, chills, chest pain, dyspnea. No complaint of problem with bowel or bladder. Discussed Premarin at length. See review of systems. See PCMH. All questions answered.
Provider is trying to bill as wellness visit. It could have been billed as Welcome to Medicare if this had been done. I am at a loss as to how to bill this. There are no diagnoses, just the Z00.00.

Any help is appreciated.
 
You will need to go with an exam such as Z00.00 for the dx. You cannot use long term or current use of hormones as that was not the reason for the exam. You could look under administrative exams also but I think welcome to Medicare fits what you have described.
 
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