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Wiki Patient Refuses Exam

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A physician sees a patient for a subsequent hospital visit. Patient with multiple chronic conditions which are uncontrolled due to noncompliance. Patient also with MH issues - patient refuses exam. MD does have face to face encounter with patient and documents vital signs and psych exam elements only. Provider codes 99233- hx is expanded, MDM is comprehensive. Can provider get full credit for exam because patient refuses a more comprehensive exam?
 
Unlike the unobtainable history, I have never seen any guideline that says that you can give a provider credit for an exam that was not performed, and I don't believe any payer would audit this way. A comprehensive exam is a significant amount of provider work, and my feeling is that it would be overvaluing the encounter to give credit for a comprehensive exam if no exam was performed. I would code the encounter based only on what is documented.
 
This is for subsequent visit, so only requires 2 of 3 components. Since 1 component (exam) was not performed, you have to code based only on expanded history and "comprehensive" (which I am assuming is high complexity) MDM. You are left with 99232, since 99233 would require detailed interval history.
 
Document Refused Exam

I would also suggest the provider document that the patient refused the exam and any surrounding conversation especially considering the noncompliance issues.
 
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