billable or not


Best answers
A new patient to our pain clinic was seen, ROS was done, vitals, history, but because of the patients history of drug abuse, was informed that we would not perscribe pain medication but could look at other options. He left without an exam. Can we bill for an office visit?
Let's hope others will comment on this example. Perhaps you should call the carrier and ask if they accept the unlisted EM code of 99499 and be prepared to submit the chart notes. It seems to be the only choise available due to the fact that an exam was not performed. I've seen discussion concerning this and it might be worth a try. ---Suzanne E. Byrum CPC
Since the patient did not see the provider I don't think you can bill for anything. Exam is an intergral part of the E & M and with out it there is nothing for a new patient visit.
Was any exam documented

I have seen this done when the physician commented on the general appearance of the patient before he left - in that case, I gave a level 1 with the one exam element of constitutional (1995 guidelines). Maybe a stretch, but it did pass muster with an auditor! :)