Could someone clarify the appropriate coding for “establish care” visits? We’re encountering a situation where Internal Medicine providers are billing 99203-99205 for new patient visits classified as “establish care,” even when patients present with no specific health concerns or abnormalities. These visits are often coded with Z00.00 (Encounter for general adult medical examination) and Z71.2 (Person consulting for explanation of or advice on other and unspecified findings).
The crux of the issue is that to justifiably bill for a sick visit, there’s an expectation that a problem is addressed, lab results are reviewed, or ongoing management is performed. This raises the question: How should Evaluation and Management (E/M) levels be accurately calculated in scenarios where a new patient seeks to establish care without any acute or chronic health issues needing immediate attention? Furthermore, what are the correct diagnosis pointers to utilize in these specific instances?
For example, consider a new patient presenting solely to establish primary care. During the visit, she reports no current medications or medical conditions. She mentions upcoming appointments for a routine gynecological exam and annual eye check, and a planned dental visit. Her last primary care visit was several years prior, in 2017. She provides details on her regular menstrual cycle and denies any period-related pain. She acknowledges slight anxiety in medical settings and denies any acute symptoms like nausea, vomiting, bladder issues, or sleep disturbances. While she mentions intermittent headaches following a minor head bump a few weeks prior, she denies concussion symptoms and did not seek medical attention. She also denies any ear, nose, or throat complaints. Family history includes paternal diabetes and maternal grandmother with thyroid and chemotherapy history. She is married, a non-smoker, and denies substance use. She works as an administrative and lab assistant, maintains a healthy diet, and exercises regularly.
In such cases, where a new patient is essentially establishing a relationship with a primary care provider for wellness and future healthcare needs rather than addressing a current medical problem, how should these “establish care” visits be appropriately coded and documented to reflect the service provided without misrepresenting them as problem-focused encounters?
