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

[jackieconvery12]

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?

 

[rachaelwilleford]

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.