Forum - Questions & Answers

Apr 27th, 2012 - coder0370

Determine preventive vs sick visit

Good Morning,
I have a patient who wants to establish with a provider. Her chief complaint is "generalized complaints." The HPI starts with "pt here to establish care" and then describes some past problems (hypotension during colonoscopy) and some new/chronic problems (joint pain, COPD). The provider does not elaborate on any problem. A comprehensive ROS and exam is done. The assessment says to stay on current treatment, but does order a test. Should this be a preventive visit? I have been told to check what is documented in the CC, but I am not sure about this visit.
Thanks!



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