How does one report a preventive medicine visit and sick visit on the same date of service for a new patient?

This is a question that is asked frequently and presents a coding quandary. During a preventive medicine visit for a new patient, if an abnormality or condition requires additional physician work, should the problem-oriented visit be reported as a new or an established patient visit?

The correct answer, from the prospective of Current Procedural Terminology (CPT®), is that when both services are provided to the patient on the same day of service it would be appropriate to report both the preventive medicine visit and the problem-oriented visit with new patient codes. Note that CPT guidelines state, “If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require...

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