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.
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