Wiki combining documentation from 2 E/M on same DOS


melbourne, FL
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I have an OB/GYN who saw a patient in the office with elevated Blood Sugar and admitted her to the hospital. He went back on 2 separate occasions and saw this patient, duplicating some of the exam elements. Now I know that you are to combine the visits and code the E/M based on the documentation. My problem is do you count the two exams twice or only once? Can someone out there help me? Thanks, Lynn Kimsey, CPC
If you counted them twice, that wouldn't really do anything to your E&M level.... vitals are vitals and you don't get any "extra credit" anywhere in the exam elements for doing them twice.

:) Erica
OK, that is what we were thinking but you know how you start to doubt yourself when you overthink something. Thanks for the response. Lynn