mracioppi
Contributor
Can anyone tell me if an E/M visit can be billed if the patient's vital were taken but not documented at the TOS? The claim has already been billed to a commercial insurance co.
It depends on which level you billed.
Simone
I am assuming you are talking about the physical exam portion. If you have enough bullets in the physical exam to cover a level 4 you should be fine, you don't have to have the constitutional points to get a four as long as there is enough others mentioned to cover.