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Thread: Help with exam level

  1. #1
    Join Date
    Apr 2007
    Harrisburg, PA

    Default Help with exam level

    AAPC: Back to School
    I am auditing an office visit on a patient who is at the surgeon's office for a followup to mammogram and ultrasound of the breast.

    No where in the note in there any physical exam. Would I consider this exam as problem focused?

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Follow-up = established patient

    So this is an established patient? You can code based on History and MDM.

    If you have NO exam ... then you have NO exam (Not the same as problem-focused, which IS an exam)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Join Date
    Apr 2007
    Harrisburg, PA


    That is what I thought. Thanks

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