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Coding preventive care code amd OV code on same day
A 52-year-old established patient presents for an annual exam for the first time. When pt is asked about his current complaints, he mentioned that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. Dr take's additional history related to his symptoms, perform a detailed respiratory and CV exam, and order an electrocardiogram and chest X-ray. Dr made a diagnosis of acute bronchitis with chest pain and prescribed medication and bed rest along with instructions to stop smoking. Also documented both the problem-oriented and the preventive components of the encounter in detail.
So my question is do we need to code 99396 or 99386 along with established E/M with 25 in this scenario
re: Coding preventive care code amd OV code on same day
Since the patient is established patient it should go as 99396 along with the E /M-25