E/M level when exam not done

chasarmil

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I am reviewing documentation for a new patient and under the exam portion the doctor wrote exam is deferred at the request of the patient due to severe migraine and having too much pain for an exam to be completed. He is A&O X 3, sitting with sunglasses on and eyes closed.
I should mention that we are a pain clinic and patient came in for a consult for head pain, lower back pain, and neck.

Doctor wants to bill it as a complete exam.
I say that without an exam, the level would only be a 1.
Dr states that if we revise our documentation to state that each body system exam was refused by the patient due to pain, we can still count it.

Looking for expert opinions.

Thanks
 

Love Coding!

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I am reviewing documentation for a new patient and under the exam portion the doctor wrote exam is deferred at the request of the patient due to severe migraine and having too much pain for an exam to be completed. He is A&O X 3, sitting with sunglasses on and eyes closed.
I should mention that we are a pain clinic and patient came in for a consult for head pain, lower back pain, and neck.

Doctor wants to bill it as a complete exam.
I say that without an exam, the level would only be a 1.
Dr states that if we revise our documentation to state that each body system exam was refused by the patient due to pain, we can still count it.

Looking for expert opinions.

Thanks
He can bill based on how much time he spent with the patient, if over 50% of the visit was spent on coordinating and talking about care options. When billing based soley on time, E/M elements are not a factor as long as there is a valid chief complaint for the visit and the documentation thouroughly shows how the time was spent...
 
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