I am reviewing documentation for a new patient and under the exam portion the doctor wrote exam is deferred at the request of the patient due to severe migraine and having too much pain for an exam to be completed. He is A&O X 3, sitting with sunglasses on and eyes closed.
I should mention that we are a pain clinic and patient came in for a consult for head pain, lower back pain, and neck.
Doctor wants to bill it as a complete exam.
I say that without an exam, the level would only be a 1.
Dr states that if we revise our documentation to state that each body system exam was refused by the patient due to pain, we can still count it.
Looking for expert opinions.
Thanks
I should mention that we are a pain clinic and patient came in for a consult for head pain, lower back pain, and neck.
Doctor wants to bill it as a complete exam.
I say that without an exam, the level would only be a 1.
Dr states that if we revise our documentation to state that each body system exam was refused by the patient due to pain, we can still count it.
Looking for expert opinions.
Thanks