Wiki Exam - Can you give credit

[Gemini18]

Can you give credit for an exam that the physician tried to perform but the patient was very uncooperative. Pt has severe Alzheimer's and very uncooperative -- it is stated in the exam.

I have:

General: This is an uncooperative patient who was not oriented to time and place.
Lungs: Clear to auscultation
Cardio: RRR
Abd: soft
Extremities: No edem

 

[FTessaBartels]

1995 guidelines

Using 1995 guidelines you have an EPF exam

Is this a new patient or an existing patient? What is the MDM? What is the history? If it's existing you can code without any exam, using history & MDM as your qualifying elements for the level of service.

Hope that helps - Not really sure what your question is.

F Tessa Bartels, CPC, CEMC