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Wiki Does the assessment count as the reason for the visit?

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jackieconvery12

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Washington Twp, MI
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We are billing for botox injections. The physician documents the pt is here for botox. Then details the procedure being done, then towards the bottom he documents assessment: chronic migraine.

Would the assessment count as the reason for the visit?
 
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If the patient is only there for the botox injection, there has to be something over and above for the provider to bill for an e/m. Otherwise, you can only bill for the injection.

That presenting problem has been an issue with providers not understanding that "here for treatment" is not a valid presenting problem. Documented assessed problems warranting the treatment would be the diagnosis for the injection.
 
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