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Exam component

  1. #1
    Red face Exam component
    Medical Coding Books
    I have a physician that stated in the patients chart that the Physical Exam was Deferred. Does anybody know how to count this?

    Please help???
    Kristen, CPC
    Kristen Richard, CPC

  2. #2
    Phoenix, AZ
    Why was it deferred? If the patient was not present, the visit is not billable.
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  3. #3
    I don't know why he dictacted that the exam was deferred. Theres no explanation. But I do know that the patient was present. Doc spent 50 minutes with the patient, all of which was in consultation reveiwing the patients history and diagnosis.
    Kristen Richard, CPC

  4. #4
    You get no credit in exam for "deferred" that means it wasn't done.

    It sounds like this should be billed on time if documented properly, which makes the key components a non-issue.

    If the provider documented total time and amount spent counseling/coordinating care (which must be greater than 50%) you just level based on time.

    They do not have to say "greater than 50%", they can though. If he documented "I spent 50min with patient discussing (fill in the blank)" then I would use the level that 50 min falls in. Because he spent 100% of the 50 minutes it qualifies.

    Laura, CPC, CEMC

  5. #5
    Thank you Laura,
    Kristen Richard, CPC

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