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combining documentation from 2 E/M on same DOS

  1. #1
    Default combining documentation from 2 E/M on same DOS
    Medical Coding Books
    I have an OB/GYN who saw a patient in the office with elevated Blood Sugar and admitted her to the hospital. He went back on 2 separate occasions and saw this patient, duplicating some of the exam elements. Now I know that you are to combine the visits and code the E/M based on the documentation. My problem is do you count the two exams twice or only once? Can someone out there help me? Thanks, Lynn Kimsey, CPC

  2. #2
    If you counted them twice, that wouldn't really do anything to your E&M level.... vitals are vitals and you don't get any "extra credit" anywhere in the exam elements for doing them twice.


  3. #3
    OK, that is what we were thinking but you know how you start to doubt yourself when you overthink something. Thanks for the response. Lynn

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