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Help with exam level

  1. #1
    Harrisburg, PA
    Default Help with exam level
    Exam Training Packages
    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
    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
    Harrisburg, PA
    That is what I thought. Thanks

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