e/m ?

samyjm13

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Meridian, ID
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A new patient came into the clinic for a follow up from being in ER for a miscarry, the documentation has a HPI, PFSH, ROS, but the examination was deferred. I am having a hard time getting a level with no exam. Would I code the lowest level or query the doctor on how much time was spent with the patient?
The doctor wants her to come back in 3 weeks for an annual.

thanks
 

missy874

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Albany
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A new patient visit requires all three components, therefore without an examination (or time statement) this is non billable. I would query the provider to see if an addendum is possible for time spent counseling and/or coordination of care--provided that was greater than 50% of the visit.
 
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