kbarron
Guest
Pt admitted for pelvic pain, complicated PMH. Request by PCP for gyn input re management of pelvic pain and irreg vag bleeding. I read the note and it states pt declines any Physical Exam. Further, note states" I spent 60 minutes with pt and mother discussing her concerns. The pt was able to contribute intermittently although she was extremely somnolent." I want to give it a 99253. Am being told that exam was not done. I believe that I can code it this was. Would love any and all input. Thanks