Wiki New Patient Visit w/out Exam

[catrina.thomas]

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]

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,