Could someone offer guidance on addressing a practical issue concerning coding for the establishment of care in internal medicine? We’ve observed instances where providers are billing 99203-99205 for new patient visits designated as “establish care,” even when there are no reported abnormalities or specific health concerns. In these cases, diagnoses codes Z00.00 (Encounter for general adult medical examination without abnormal findings) and Z71.2 (Counseling and education related to diet and physical activity) are being used alongside the office visit codes.
The fundamental question arises: to appropriately bill for a sick visit, isn’t it necessary for a problem to be addressed, or for lab results to be reviewed and managed? How should Evaluation and Management (E/M) codes be accurately calculated in these particular scenarios, and what are the appropriate diagnosis pointers to utilize?
Consider this example: A new patient presents today to establish care with our practice. The patient explicitly states she is not currently taking any medications and denies any pre-existing medical conditions. She has a scheduled appointment with her gynecologist later today for a routine Pap smear, her first ever. She mentions annual eye exams due to poor vision and a forthcoming dental appointment on Wednesday. It’s noted that she hasn’t seen a primary care physician in several years, with her last visit recorded in 2017. Her menstrual cycle is regular, with her last period occurring from January 10th to 16th, and she reports no unusual period pain. She is sexually active. She admits to feeling slightly anxious about being in a doctor’s office. She denies experiencing nausea, vomiting, bladder issues, or sleep disturbances. Neck pain and blurred vision are also denied. She does mention intermittent headaches for a few weeks following a fall where she hit her head on a bathtub, but she didn’t seek medical attention and doesn’t believe she sustained a concussion. She denies ear pain, drainage, or ringing. Sore throat is also denied. Her father has a history of diabetes, and she notes her grandmother’s recent hospitalizations for thyroid issues and chemotherapy, though details are unclear. She is married, a non-smoker, and denies any use of tobacco, marijuana, alcohol, or illicit drugs. She works as an administrative and lab assistant. She is actively trying to improve her diet by cooking at home more and exercises at least five times a week.
In situations like this, where a new patient seeks to establish care without presenting specific health issues requiring immediate medical intervention, what is the correct coding approach for E/M services? Guidance on the appropriate use of 99203-99205 codes and the application of diagnosis codes like Z00.00 and Z71.2 in the context of “Coding For Establishment Of Care” is needed to ensure accurate and compliant billing practices.
