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Wiki E/M Help!

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Jennae929

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I have a few different questions to ask!

1. Does anyone have Orthopedic type examples for MDM? I think I might be scoring at a higher complexity than I should be.

2. In regards to the Exam - If a Physician documents that the patients complaints and exam have remained unchanged and consistent with the dx of impingement w/ significant rotator cuff tendinopathy ... can I use the last exam information?

3. If a Physician is seeing a patient and during the visit they decide to go with the option for surgery and the physician completes a History & Physical during the visit, does the H&P information count toward the overall office visit?

Thank you!! :confused:
 
You can't reference an old exam.

You can reference an old Review of Systems or in the hospital setting, you can reference another physician's ROS. You have to give the date of the ROS that is referenced though. For example: "ROS unchanged from 12/25/2014."

You can also reference PSFH if you give the date.

You would charge the H&P from that day with a modifier 57 if the patient made a decision for surgery and was going to have surgery that day or the next.

If you give me your email address I can send you some guidance on how to select E/M codes.
 
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