Can provider bill for E/M office visit when the patient was not present? Physician met with parents of severely disabled young adult. The patient did not accompany them to the office visit.
Below is a typed copy of the note.
Patient: John Doe
Age over 30
Established patient
DOS: 2013
Subjective Findings:
John Doe’s parents are in for an appointment regarding John Doe. John Doe has been QT chromosomal abnormality, autism spectrum disorder C are severe intellectual disability, global developmental disorder, adult growth hormone deficiency hypotonia, osteoporosis and scoliosis and oral motor dyspraxia.
He is currently taking vitamin K twice daily for osteoporosis. He was on alendronate for approximately 6 years. This was subsequently discontinued. He is taking calcium supplement as well as a vitamin D supplement. He is also on growth hormone adult growth hormone deficiency.
His most recent 1 just one reviewed. Treatment plan reviewed with parents.
Problem list: (all are identified as chronic)
Hypotonia
Global Developmental delay
Mental retardation
Acne
Cerebral palsy
Osteoporosis
Autism
Growth hormone deficiency
Abnormal chromosome
Past Medical/Surgical History
Anoxia at birth/pneumothorax
Cryptorchidism-orchiopexy and hernia repair
Far sighted
Hip fracture right femoral neck nondisplaced
Infection left inguinal hernia
Right knee fracture
Right knee injury (medial collateral ligament
Surgery for rectal prolapse
Surgery upper spine, scoliosis
Diagnostic History
Dexi Scan
Family History:
Reviewed, no changes. Last detailed document xx/xx/2012
Social History:
Reviewed no changes. Last detailed document date xx/xx/2012
Allergies:
Droperidol
Meperidine HCL
Benzodiazepines
Labs results received last 30 days:
Vitamin D, 25-Hydroxy,LC/MS/MS
Lab values listed here
IGF I, LC/MS
Lab values listed here
Lipid Panel
Lab values listed here
Comprehensive Metabolic Panel
Lab values listed here
Assessment/Plan
Osteoporosis (733.00) chronic
Pituitary dwarfism (253.3) chronic
John Doe is scheduled in the near future for repeat bone density Test if he has fallen bone density would discuss treatment options which include Prolia. Currently will continue on over the counter treatment. Parents reassured. Total time spent with x 30 min.
Medications:
Current medications listed here
Counseling/Education Factors:
Counseling/Education factors reviewed
Provider: Doctor’s name, MD
Authenticated by Doctor’s name, MD on xxx date
Below is a typed copy of the note.
Patient: John Doe
Age over 30
Established patient
DOS: 2013
Subjective Findings:
John Doe’s parents are in for an appointment regarding John Doe. John Doe has been QT chromosomal abnormality, autism spectrum disorder C are severe intellectual disability, global developmental disorder, adult growth hormone deficiency hypotonia, osteoporosis and scoliosis and oral motor dyspraxia.
He is currently taking vitamin K twice daily for osteoporosis. He was on alendronate for approximately 6 years. This was subsequently discontinued. He is taking calcium supplement as well as a vitamin D supplement. He is also on growth hormone adult growth hormone deficiency.
His most recent 1 just one reviewed. Treatment plan reviewed with parents.
Problem list: (all are identified as chronic)
Hypotonia
Global Developmental delay
Mental retardation
Acne
Cerebral palsy
Osteoporosis
Autism
Growth hormone deficiency
Abnormal chromosome
Past Medical/Surgical History
Anoxia at birth/pneumothorax
Cryptorchidism-orchiopexy and hernia repair
Far sighted
Hip fracture right femoral neck nondisplaced
Infection left inguinal hernia
Right knee fracture
Right knee injury (medial collateral ligament
Surgery for rectal prolapse
Surgery upper spine, scoliosis
Diagnostic History
Dexi Scan
Family History:
Reviewed, no changes. Last detailed document xx/xx/2012
Social History:
Reviewed no changes. Last detailed document date xx/xx/2012
Allergies:
Droperidol
Meperidine HCL
Benzodiazepines
Labs results received last 30 days:
Vitamin D, 25-Hydroxy,LC/MS/MS
Lab values listed here
IGF I, LC/MS
Lab values listed here
Lipid Panel
Lab values listed here
Comprehensive Metabolic Panel
Lab values listed here
Assessment/Plan
Osteoporosis (733.00) chronic
Pituitary dwarfism (253.3) chronic
John Doe is scheduled in the near future for repeat bone density Test if he has fallen bone density would discuss treatment options which include Prolia. Currently will continue on over the counter treatment. Parents reassured. Total time spent with x 30 min.
Medications:
Current medications listed here
Counseling/Education Factors:
Counseling/Education factors reviewed
Provider: Doctor’s name, MD
Authenticated by Doctor’s name, MD on xxx date