Here is one scenario. A new patient comes in for an annual wwe. In addition, she has shoulder pain for a year. I coded this as a 99386 for the wwe, and then a second e/m code of 99212 and attached modifier 25 for the shoulder pain. My question is, was this correct? Is she now an “established” patient after the first visit for the well woman exam (wwe), and even though the other visit was simultaneous on the same day, is it established as a 99212 or should it have been a 99202? I also heard there needs to be two separate notes written up..

Scenario number two: Another new patient comes in for a wwe. Part of her wwe includes a gynecological problem that she wishes to discuss and be worked up. She also wants counsel and ocp start. I figure all of this has to go under the 99385 code. Now she also had an eating disorder and rapid unintentional weight gain, and wanted to discuss this and get thyroid testing, as three of her family members had thyroid abnormalities. So I drew blood, and worked up her weight gain issue. So, is the ICD 9 of unintentional weight gain under a second E/M code of 99212 with a modifier 25, or would this all go under 99385 with a modifier 21 for extra time, as the visit took one hour? Anyone know? Carla Anderson, Healing Presence Family Practice, PC