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Thread: Patient stating they only came in for Annual Pe

  1. #1

    Default Patient stating they only came in for Annual Pe

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    Last edited by cnramsey; 09-23-2010 at 02:31 PM.

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    It looks like the PE to me. Honestly I do not believe you can charge an office visit in addition without informing the patient. If the patient had a symptomatic issue then the physician could explain that there would need to be an additional visit charged or the same thing if the physician discovers an issue that needs to be addressed. But to do an annaul and then tack on and office visit and a level 4 at that does not seem right. Also I was instructed from numerous carriers that if the physician was going to charge an annual and an ov on the same day that there needs to be two separate office notes, one for the annual and one for the ov. At least then it would be clear. I think the patient is correct on this one.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007
    Savannah, GA


    I agree I would code just a PE. We had the same issue here. Our EMR system will automatically add the office visit if the physician adds additional dx to the chart which they sometimes do just to refill meds or order mammos, etc. I now have the patients complete an annual physical form. In it states that “physical or preventive exam” does not include evaluation of specific medical problems" and that if they prefer to address those specific problems we can do that and reschedule their physical. This just clarifies everything before they are taken back to see the doctor.

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