dballard2004
True Blue
A new patient comes into the clinic for a travel exam because they are going overseas. The CC states the following:
Need for malaria prophylaxis; will be traveling to Mexico/bordering Belize
Is this a valid CC to constitute a new patient visit? The HPI has when the patient is leaving and when they will be returning. It also states that the patient denies any renal disease, liver disease and pregnancy. I don't see this as associated signs and symptoms because there is no complaint to tie this to. An exam was performed and the patient was given a prescription for a malaria prophylatic pill.
The provider coded this as a 99202. I say that without a valid CC or HPI, the history level is not there and the key components are not met.
Can we report an unlisted E/M for this? No counseling is documented so 99401 is not an option.
Any advice is appreciated.
Thanks.
Need for malaria prophylaxis; will be traveling to Mexico/bordering Belize
Is this a valid CC to constitute a new patient visit? The HPI has when the patient is leaving and when they will be returning. It also states that the patient denies any renal disease, liver disease and pregnancy. I don't see this as associated signs and symptoms because there is no complaint to tie this to. An exam was performed and the patient was given a prescription for a malaria prophylatic pill.
The provider coded this as a 99202. I say that without a valid CC or HPI, the history level is not there and the key components are not met.
Can we report an unlisted E/M for this? No counseling is documented so 99401 is not an option.
Any advice is appreciated.
Thanks.