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Wiki Exam component

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krssy70

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I have a physician that stated in the patients chart that the Physical Exam was Deferred. Does anybody know how to count this?

Please help???:o
Kristen, CPC
 
I don't know why he dictacted that the exam was deferred. Theres no explanation. But I do know that the patient was present. Doc spent 50 minutes with the patient, all of which was in consultation reveiwing the patients history and diagnosis.
 
You get no credit in exam for "deferred" that means it wasn't done.

It sounds like this should be billed on time if documented properly, which makes the key components a non-issue.

If the provider documented total time and amount spent counseling/coordinating care (which must be greater than 50%) you just level based on time.

They do not have to say "greater than 50%", they can though. If he documented "I spent 50min with patient discussing (fill in the blank)" then I would use the level that 50 min falls in. Because he spent 100% of the 50 minutes it qualifies.

Laura, CPC, CEMC
 
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