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Exam - Can you give credit

  1. #1
    Question Exam - Can you give credit
    Medical Coding Books
    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
    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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