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Wiki annual with /without problems

swiedner7

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Does anyone know where I can find a definitive answer as to what constitutes a problem and how to code for it? Doctor codes a visit as without problems but lists dx for problems but didn't really do enough work to justify a separate e/m code. Or if coded as with problems does that mean we should be charging another visit? there was not a lot of specific training on gyn codes!
 
If you read the codes, the category description says it all.. General exam without complaint, suspected, or reported diagnosis.. Then the excludes 1 note seals it. Excludes 1 encounter for signs and symptoms- code to the signs and symptoms. If the provider discovers something abnormal while the patient is here for the annual the. You would use the choice that specifies with abnormal finding and list the abnormality second.
 
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