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CPT coding for a new patient AW with an acute problem that was addressed

I’m wondering if I’m over thinking this ,would appreciate advise
New pt AW ,this patient is transferring care to his new PCP he has co morbidities like HTN ,NIDDM he brings in meds to verify ,records have not been transferred yet
The Provider does the AW and updates the medical record with conditions that are supported by medication
In addition to the AW visit the pt c/o an acute problem like a sinus infection
Code the new pt AW with CPT 99381-99387
my question is now how do you code the Acute problem that was addressed during the visit,assuming it was problem focused with straightforward or expanded problem focused MDM ? would you use 99202(new Pt) or 99212 (established)
I honestly don’t know for certain which way to go on this I would think the established however not certain
Thank you in advance for any help
Cheri

Medical Billing and Coding Forum

HPI items not addressed

Good Afternoon Everyone,

CC: medication refill

HPI: Patient here for medication refills. Pt has type 2 DM, HTN, HLD, GERD. Patient reports poor compliance with meds and out of BP meds about 2 wks.

Of note; Lisinopril, Metformin and issue of repeat prescription for Prilosec. Controlled on current medication dose and regimen.

Would you consider the following a true statement in regards to this scenario?

"You must document the conditions you didn’t address (eg; HLD and chronic pain not addressed during this encounter")

Thank you for your time
Lyn

Medical Billing and Coding Forum