Forum - Questions & Answers

Jan 19th, 2010 - carfio

"Establish Care"

Patient comes in to establish care with Dr. Dr wants to bill an E/M visit, new patient. There is no HPI, patient has no complaints. Dr does comprehensive PFSH and a Problem Focused exam and Straight Forward MDM.
Can we bill an level of service? New patients require 3 of 3 components, without the HPI, how can we bill a level of service? Dr is wanting to bill a PE under the same circumstances for a different patient.
Any opinions would be greatly appreciated.
Carfio

Jan 19th, 2010 -

I would

Bill the both as Physical exam 99381-7- there are no definitive requirements for documentation as with E&M visits.

the first patient must have come in for a reason- a check up?- then it is a physical. If it was to get refills on meds for a chronic problem (that's the HPI)? Then it fits E&M.

Jan 24th, 2010 - Codapedia Editor 1,399 

establish care

options:

Don't do them.
Do them for free.
Insist on doing an exam.
Bill based on time, IF it meets criteria.
Insist all patients start with a PE.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association