Not sure how to code this visit. 9 year old patient had a well child visit on 07/30/2018, but would not let the female provider perform the genitourinary exam due to history of sexual abuse. Returned on 08/08/2018 to have this exam performed by a male provider. Male provider also explained puberty and physical changes the patient would be experiencing in the next few years. Does this warrant a preventive visit or problem-focused? Can we code a preventive visit that soon? Can I code a problem focused e/m with Z00.3 and Z62.010. Any thoughts would be greatly appreciated.
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