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Wiki Help with exam level

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cbooker

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I am auditing an office visit on a patient who is at the surgeon's office for a followup to mammogram and ultrasound of the breast.

No where in the note in there any physical exam. Would I consider this exam as problem focused?
 
Follow-up = established patient

So this is an established patient? You can code based on History and MDM.

If you have NO exam ... then you have NO exam (Not the same as problem-focused, which IS an exam)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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