We have a patient who had an elective abortion at an external facility. She came to see our CNM for follow up care. The provider coded 67.9 - unspecified follow-up exam, and billed with a 99213. Insurance denied as: THESE SERVICES ARE NOT USUALLY ASSOCIATED WITH THIS DIAGNOSIS.
HPI: 15 yo F here with her mother for post AB followup ; done Jan 9th 2014 at 8 weeks gest age. Bleeding since procedure - now light. Seen in ER 3 days ago with chest discomfort ;diagnosed with GERD; treated with mylanta with relief. Taking prilosec as prescribed 2 weeks ago.
BCM- none now ; interested in ortho evra.
Brief exam:
General Appearance Pleasant, NAD, Well-developed, well-nourished, No Resp Distress, AOX3. ABDOMEN: no guarding or rigidity, no masses felt. PSYCHIATRIC: quiet. GENITALIA - female normal hair distribution, vaginal mucosa clear without lesions , very scant brown mucoid discharge, cervix firm, clear & closed, no CMT, no adnexal tenderness, normal uterus.
Assessments
1. post termination exam - V67.9 (Primary)
2. contraceptive F.P. Advice - V25.09
Treatment
1. post termination exam
condom use strongly emphasized *Medications reconciled with patient, *Patient expresses good understanding of issue(s) and agrees to treatment plan. For answers to medically related questions, please visit to use Up To Date link. greater than 50% of the visit was spent in consultation and coordination of care. Total face to face time greater than 15 minutes.
2. contraceptive F.P. Advice
Start Ortho Evra film, extended release, 20 mcg-150 mcg/24 hr, 1 PATCH, transdermally, once a week, 3 week(s), PATCH, Refills 3
options discussed wiwth pt and her mother ; pt desires contraceptive patch; risks and benefits discussed ; consent read and signed *Medications reconciled with patient, *Patient expresses good understanding of issue(s) and agrees to treatment plan. For answers to medically related questions, please visit to use Up To Date link. discuss AIDS,STIS,BCMS counseling,and education.
Any suggestions on a more appropriate dx code?
Thanks in advance.
Arrana Ashton, CPC
HPI: 15 yo F here with her mother for post AB followup ; done Jan 9th 2014 at 8 weeks gest age. Bleeding since procedure - now light. Seen in ER 3 days ago with chest discomfort ;diagnosed with GERD; treated with mylanta with relief. Taking prilosec as prescribed 2 weeks ago.
BCM- none now ; interested in ortho evra.
Brief exam:
General Appearance Pleasant, NAD, Well-developed, well-nourished, No Resp Distress, AOX3. ABDOMEN: no guarding or rigidity, no masses felt. PSYCHIATRIC: quiet. GENITALIA - female normal hair distribution, vaginal mucosa clear without lesions , very scant brown mucoid discharge, cervix firm, clear & closed, no CMT, no adnexal tenderness, normal uterus.
Assessments
1. post termination exam - V67.9 (Primary)
2. contraceptive F.P. Advice - V25.09
Treatment
1. post termination exam
condom use strongly emphasized *Medications reconciled with patient, *Patient expresses good understanding of issue(s) and agrees to treatment plan. For answers to medically related questions, please visit to use Up To Date link. greater than 50% of the visit was spent in consultation and coordination of care. Total face to face time greater than 15 minutes.
2. contraceptive F.P. Advice
Start Ortho Evra film, extended release, 20 mcg-150 mcg/24 hr, 1 PATCH, transdermally, once a week, 3 week(s), PATCH, Refills 3
options discussed wiwth pt and her mother ; pt desires contraceptive patch; risks and benefits discussed ; consent read and signed *Medications reconciled with patient, *Patient expresses good understanding of issue(s) and agrees to treatment plan. For answers to medically related questions, please visit to use Up To Date link. discuss AIDS,STIS,BCMS counseling,and education.
Any suggestions on a more appropriate dx code?
Thanks in advance.
Arrana Ashton, CPC
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