Hi,
If my physician sees a new pt. and does a history and D/m but no exam, he does state "the patient's history and exam is stable from Dr.xxxxxxx recent dictation."
He does not state the date of that recent dictation.
My question is can I bill this if he didn't do the exam, this pt. is new and we must meet three out three to get the level. Time is not documented so I can not bill based on time.
Any thoughts, please,
Marci Klaubauf, CPC
If my physician sees a new pt. and does a history and D/m but no exam, he does state "the patient's history and exam is stable from Dr.xxxxxxx recent dictation."
He does not state the date of that recent dictation.
My question is can I bill this if he didn't do the exam, this pt. is new and we must meet three out three to get the level. Time is not documented so I can not bill based on time.
Any thoughts, please,
Marci Klaubauf, CPC