Wiki Well visit and infertility discussion

[caroline75771]

Hello All,
Would like to know if you agree with billing both preventive code and EM for discussion of infertility.
Any thoughts would be greatly appreciated! Thank you.
See below:

Allergies: No Known Allergies.
Vital Signs
Entered weight: 98 lb., 6 oz.
Calculated Weight: 98.38 lb. (44.72 kg.)
Height: 63 in. (160.02 cm.)
Body Mass Index: 17.49
Body Surface Area (m2): 1.43
Blood Pressure: 98/66 mm Hg

Urinalysis (dipstick)
Protein: neg; Glucose: neg mg/dl;

LMP: 01/17/2011
Last Pap: WNL (02/19/2010 9:39:55 AM)
Age 1st Menses: 14
Frequency: 42
Duration: 5
Hx of Abnormal Pap: No


Chief Complaint: Annual exam
History of Present Illness:
The patient presents for an annual exam.The patient states that she is sexually active with one partner., The patient denies a history of STD's., The patient reports that her last pap smear was normal.The patient reports that she is currently using nothing for contraception.
Patient reports irregular menstrual cycles. Stopped breastfeeding 7/2010. Has a history of irregular cycles q48-62 days. Planning to start trying to conceive.


Pregnancy History
Total Preg.: 3
Full Term: 1
Premature: 0
Ab. Induced: 0
Ab. Spontaneous: 2
Ectopics: 0
Multiple Births: 0
Living: 1

Pregnancy #1
Delivery date: 05/23/2008
Comments/Complications: Spont AB

Pregnancy #2
Delivery date: 01/12/2009
Comments/Complications: spont ab

Pregnancy #3
Delivery date: 01/03/2010
Type of anesthesia: epidural
Delivery type: NSVD
Birth weight: 7-0
Sex: Male
Baby's Name: CARTER
Delivery location: WPH
Comments/Complications: MA- VIACORD collection. spont labor. baby devel neonatal mastitis- on augmentin.

Past Medical, Family, and Social History

Past Medical History (reviewed - no changes required): Herpes simplex Virus- Type 1

Past Surgical History: D & C - 5/23/08, 1/12/2009 due to spont ab; chromsomes 69XXX for first; 46XY for second
IUI - 4/12/2009


Family History (reviewed - no changes required): Basal Cell Ca-F
Hypertension-F


Social History: Dentist- madison Ave
Married
Graduate School

Review of Systems
General: negative
Eyes: negative
Ears/Nose/Throat: negative
Cardiovascular: negative
Respiratory: negative
Breast: negative
Gastrointestinal: negative
Genitourinary: negative
Sexuality: negative
Musculoskeletal: negative
Skin: negative
Neurologic: negative
Psychiatric: negative
Endocrine: negative
Heme/lymphatic: negative
Allergic/Immunologic: negative


Physical Exam
Appearance: well developed, well nourished, in no acute distress

HEENT
Head exam: normocephalic and atraumatic

Thyroid: no nodules, masses, tenderness, or enlargement
Breast exam: nontender, no masses or nipple discharge
Abdomen: soft, nontender, nondistended, no masses
Skin: intact without lesions or rashes
Lymph: normal
Extremities: no clubbing, cyanosis, edema, or deformity

Genitourinary Exam
Vulva: normal appearance, normal hair distribution, and no lesions or masses
Urethral meatus: normal
Urethra: no discharge
Bladder: no cystocele
Support: normal
Vagina: normal appearing without lesions or discharge
Cervix: normal appearance; no lesions or discharge
Uterus: normal size and position; no masses
Adnexa: no masses or tenderness
Rectal exam: normal
PAP done


Impression & Recommendations:

Problem # 1: GYNECOLOGICAL EXAMINATION, ROUTINE (ICD-V72.31)
Pap smear done
Breast and pelvic exam wnl
Encouraged self breast exams
Return to office in 1 year for routine annual exam

Orders:
Estab Phy 18-39 (99395)


Problem # 2: INFERTILITY, ANOVULATORY (ICD-628.0)
Patient with known anovulatory infertility, but has become pregnant spontaneously
Patient's cycles still irregular
Interested in conceiving in the near future
Discussed options of expectant management for 6-12 months vs. starting again with REI group to have cycles monitored
Recommended that patient continue prenatal vitamins for now -- prescription given
Referred patient to REI in NC as patient feels this may be more convenient for her given her work schedule

Spent ~15 minutes discussing this issue
Orders:
Ofc Vst, Est Level 3 (99213)


PAP Screening:
Last PAP smear: 02/19/2010
Reviewed PAP smear recommendations: PAP smear done

Osteoporosis Risk Assessment:

Risk Factors for Fracture or Low Bone Density:
Smoking status: never

Immunization & Chemoprophylaxis:
Influenza vaccine: DONE (10/01/2009)

 

[MJ4ever]

I agree with you to bill for the annual well woman and discussion for infertility. Just not sure if I would code for a level 3 compared to a level 2. Reason being that patient was recommended to start prenatal vitamins and is referred to another specialist for infertility in depth.

The WWE is a very thorough note.

 

[dan528i]

Hey I agree. Looks about right and I also think 99212 might be the right way to go.

I do have a question thats related to this issue:

Lets assume this is a new ptn. First time in the office and everything else is more or less the same. Would BOTH codes change to new or just one of them. (99385 to 99395 and 99212 to 99202). ?????

I have all carriers across the board paying for 99385 and 99203 (for example) and Only one carrier telling me (after former appeal) that "once the ptn has been seen for annual the E &M can be considered as" new". So one the codes will be denied for "New Ptn frequency visit error."

Can you guys please explain whats would be right way to go about this.


THANKS