Wiki e/m ?

[samyjm13]

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]

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.

 

[samyjm13]

Thank you