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RE:visit/No exam

  1. #1
    Default RE:visit/No exam
    Medical Coding Books
    One of our physicians saw a patient, spent about 20+ minutes taking a history and then the patient refused to be examined. Stated she had another appointment to get to. Insurance is medicare. How can she bill this? Unlisted code?
    Thanks so much

  2. #2
    Default
    Quote Originally Posted by cynthiaj54 View Post
    One of our physicians saw a patient, spent about 20+ minutes taking a history and then the patient refused to be examined. Stated she had another appointment to get to. Insurance is medicare. How can she bill this? Unlisted code?
    Thanks so much
    What do you have for history and MDM... I would make sure the physician documents that the pt "refused" or left prior to the exam...

    Now maybe I am assuming here but maybe he didn't get to MDM. If that is the case I would submit to medicare with the unlisted code and the documentation.

    Good luck,
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
    Default Exam refused
    If the provider sat there for 20 minutes, did he not notice the constitutional of the women ? Pleasant, well nourished, well developed, obese, agitated ?
    Did he not determine her psych - alert to person, place, time, Memory intact, poor historian - ?
    These are 2 areas of exam for 95 guidelines, and if documented count just as much as hands on exam. Musculoskelatal - normal gait and station,
    So if HPI, ROS and PFSH were included in his 20 minute history, Exam documented with what he observed, and MDM straightforward - What she presented with, there is an evaluation code, as only 2 out of 3 need to be met for MDM. In the ED, we have many patients who leave before tests are run, or RX - treatment plan are written, patient decides they don't want to wait any longer. Th esigns and symptoms are the primary DX, with Non-compliance as supplimental code
    If you go to a restaurant and order appetizors, eat them and then decide your main course is taking too long - do you get to leave without paying ?

    Of course - all the above needs to be documented !

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