• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

New Patient Visit w/out Exam

catrina.thomas

Contributor
Messages
24
Location
Ugene, Oregon
Best answers
0
Patient is referred to a Specialist for post op migraine pain. Patient refused a physical exam. How would you code this 45 min visit with a comprehensive history and moderate medical decision ?
 

mcpalmeter

Guru
Local Chapter Officer
Messages
192
Location
Jacksonville, Florida - 90417
Best answers
0
New Patient Visit with No Exam

I would use 99499 and submit the documentation that supports that the patient refused the exam. The only other option would be if you could bill a visit based on counseling time but your description did not specify that. In your case, it wasn't as if the physician was not willing to perform an exam or even that he/she did not think it was medically necessary, the patient simply refused. I think the physician should be compensated for the work performed but the payor may feel otherwise.

Regards,
 
Top