Wiki Preventive visit with E/M

[nc_coder]

I have attached a copy of an office note in which the physician marked a preventive care visit and a level 3 E/M. Based on the note, I don't believe the separate E/M is supported. I would like to get other opinions.
Thank you.

 

[j.monday7814]

based on the medication changes it looks like an E/M could be separately billable but the exam and CC are difficult to read and understand what he actually did. There isn't a formal legible report for this visit? Only handwritten?

 

[nc_coder]

based on the medication changes it looks like an E/M could be separately billable but the exam and CC are difficult to read and understand what he actually did. There isn't a formal legible report for this visit? Only handwritten?

Unfortunately, this is what our progress reports look like. Every once in a while they will dictate something, but the majority of our notes are like this.
Thank you for the input on the billable service. I was mixed on my opinion. I'm still not quite sure I would agree with a level 3 though.