Coding Med refills w/ nothing in note

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Can a Doctor just add to plan "refill Hypertension meds" and put nothing else in note pertaining to Hypertension?
 

CatchTheWind

True Blue
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Boca Raton, FL
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Do you mean can he bill an office visit if that is all that's in the notes? If so, the answer is no! You don't have a chief complaint, an HPI, or an exam, so there's no office visit to bill.
 
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Depends on what you are truley asking.

It sounds like you are asking if a provider can see a patient for a specific Chief Complaint, perform his E/M service, document the visit in full with his HPI, ROS, PFSH, EXAM and MDM all in place but mark that he his simply refilling a hypertension medication that is due for a refill but that hypertension may not be the reason for the visit today. In this case the answer is yes. The provider should document all treatment related and unrelated tot he CC for this DOS. He does not get points in the MDM for prescribing the hypertension medication if hypertension is not the CC, in the HPI, or part of the exam for the visit. Be careful that he is not trying to manipulate the MDM score by prescribing medications that have nothing to do with todays treatment.

If you are instead asking if the patient should be coming in for a simple medication refill that requires no face to face contact of exam with the provider. They should not, this does not require and E/M and there should be no change for refilling medications without an exam that meets medical necessity. If you have no documentation to report then a blank note with only refill documentation in the note is not billable. You can do it, it is just not billable. I hope that answers your question. :)
 
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