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Physical Exam?

  1. Default Physical Exam?
    Medical Coding Books
    My dr has admitted this pt and the H&P is perfect EXCEPT there is NO phyiscal exam documentated...What should I do? This doesn't even qualify for a level 1??


  2. Default
    I dont know what format he documents in. But I have found several times this is just an issue of ....I forgot or got interupted or the system just failed to save that portion.

    I would ask the physician if he did an exam because it's not in his note and then go from there.

  3. #3
    Default Probably depends on the carrier
    If the exam was not done and therefore can't be amended, you need to look at other codes.

    Medicare would have you use the subsequent care codes since they are 2 of 3. Unless you did a comprehensive visit within 7 days on the outpatient side, there is another set of rules for that scenario.

    I don't currently have any carriers (that I know of, it changes daily sometimes) that want the unlisted 99499 anymore, so I would default to the subsequent care for everyone in this case. Just throwing the unlisted out as an option.

    Laura, CPC, CPMA, CEMC

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