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Appropriate Chief Complaint

Kathy Posted Mon 30th of December, 2013 15:06:41 PM

Sorry, I thought I had already sent this questions but I do not seem to find it. The question is:

Can we use "6 month return visit" or "annual office visit" for an appropriate chief complaint? We are a cardiology practice in Wichita, KS

SuperCoder Answered Wed 01st of January, 2014 00:53:04 AM


We are working on this.


SuperCoder Answered Wed 01st of January, 2014 00:53:04 AM
With Editor
SuperCoder Answered Wed 01st of January, 2014 05:13:52 AM

By saying "an appropriate chief complaint", are you meaning that it's a problem-oriented CC, i.e., a problem-oriented visit? An annual office visit does not go with that. Annual office visit is usually coded with 99381-99396.

If a past visit was a problem-oriented one, then physician can recommend for a "6 month return visit" at MDM portion, and when the Pt. visits after the said time for a check-up, in that visit (RTC for a check-up) the CC depends on condition of the Pt. It either can be just a "6 month return visit" and still can be coded as 99212-99215. The same codes can apply even when the RTC visit contains a diagnosis (real problem-oriented).

When there is no diagnosis as such and Pt. visits purely for annual office visit, then you should not use 99201-99215. When there is a proper CC (diagnosis related or just a RTC for follow-up of a previous condition), 99212-99215 can be billed.

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