Forum - Questions & Answers
"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
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.
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.