I had a routine physical today with a Pap smear and also received two immunizations that I didn’t get as a child. I did not bring up any concerns. I said I was just there for preventative services. I just answered the doctor’s questions stating everything is going well with my health, mental health, sleep, diet, exercise, etc. I have previously been diagnosed with anxiety, which the doctor brought up, and I said that things are stable and going well. I’ve also been previously diagnosed with UC and Celiac, and said those things are stable too.
On the after visit summary the Diagnosis includes annual physical exam, anxiety, screening for cervical cancer, and the two vaccinations.
In the notes section the medical assistant listed “Patient presents to clinic for routine physical exam. Would like to get caught up on some vaccines. No concerns today.”
Additionally in the notes section, the doctor wrote “X is here for a physical exam. In addition to routine preventative health issues, she has the following concerns: updating all vaccination.”
Why would anxiety be listed in the diagnosis section, but not UC or Celiac? Is that going to make this billed as diagnostic, not preventative? How do they determine the nature of the visit?
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