Question:

What code can I use when a patient presents to establish care, and doesn’t
have any symptoms or problems?

Answer:

First, code or no code, isn’t this a great position for the patient to be in? Establishing care without a care in the world? (Medically at least.)

There isn’t a CPT code for “meet and greet.” The practitioner will need to bill an E/M service, either an office or other patient visit code, 99202—99215, or a preventive medicine service. And, the practitioner will need to choose a diagnosis code that supports the medical necessity for the service.

If selecting an office visit, the physician/NP/PA can select the level of service based on time or medical decision making. But, there is still the problem of the diagnosis. Will a payer pay for an office visit with code Z00.00 or Z71.89, persons encountering the health services for counseling or other medical advice, or another Z code?

The other option in these situations is to change to a preventive medicine service. This can be difficult, because only one preventive service (99381—99397) is paid for children after age 2 and adults, and the practice may not know if or when the patient has had a preventive service in the past year. And, the visit may not be scheduled with enough time, and the appropriate visit type selected in the EMR.