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Thread: Exam - Can you give credit

  1. #1
    Join Date
    Apr 2007

    Question Exam - Can you give credit

    AAPC: Back to School
    Can you give credit for an exam that the physician tried to perform but the patient was very uncooperative. Pt has severe Alzheimer's and very uncooperative -- it is stated in the exam.

    I have:

    General: This is an uncooperative patient who was not oriented to time and place.
    Lungs: Clear to auscultation
    Cardio: RRR
    Abd: soft
    Extremities: No edem

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default 1995 guidelines

    Using 1995 guidelines you have an EPF exam

    Is this a new patient or an existing patient? What is the MDM? What is the history? If it's existing you can code without any exam, using history & MDM as your qualifying elements for the level of service.

    Hope that helps - Not really sure what your question is.

    F Tessa Bartels, CPC, CEMC

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