If they came in as a planned procedure, then only the injections are coded. This would be likley for an Est patient that the physican already knows. The CC is "pt here for shots"
But, the physician also has the right to perform a medical exam to eval the patient for any medical issues that would affect the decision to travel overseas or if there were any chronic conditions that would exclude getting one of the shots.
He has the right to say "I won't give you these shots without an exam". The patient also has the right to say "Never mind, I dont need an exam, I'll go down to the Health Dept for the shots" (that would be my response).
But what would be the CC? The patient has no complaints. It would be hard to support medical necessity for a level 4 especially if your DX is only a V03-V06 code. In reality, shots can be given by the nurse.
It comes down to: did the physician have medical necessity to perform a level 4 eval on these patients? Or is he padding?
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