• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki e/m ?

Create Wiki
S

samyjm13

Guest
Messages
187
Location
Meridian, ID
Best answers
0
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
 
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.
 
You must log in or register to reply here.
Top