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incomplete exams

  1. Default incomplete exams
    Medical Coding Books
    Not sure how to code the following situations....

    situation 1: Patient has Vital Signs taken and recorded, medication information entered into their medical record, allergy info entered etc. the patient walks out before the dr. enters the room for the exam

    situation 2: same as above, and in addition CLIA tests are also done and recorded before patient walks out - prior to dr's exam.

    any suggestions?

    thanks

  2. #2
    Location
    Chesapeake, Virginia
    Posts
    16
    Default Shirley CPC, CPMA
    Hi Laura,

    New patient or established?

  3. #3
    Default face to face?
    Quote Originally Posted by laura trinca View Post
    Not sure how to code the following situations....

    situation 1: Patient has Vital Signs taken and recorded, medication information entered into their medical record, allergy info entered etc. the patient walks out before the dr. enters the room for the exam

    situation 2: same as above, and in addition CLIA tests are also done and recorded before patient walks out - prior to dr's exam.

    any suggestions?

    thanks
    In either situation... was there a face to face w/ doctor and patient. If not then there is nothing to bill. There must be a face to face between provider and patient in order to bill.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #4
    Location
    Atlanta Perimeter
    Posts
    59
    Default
    Assuming these are established patients -

    In situation 1 nothing is billable.

    In situation 2 you can bill for the CLIA test only, not any E&M codes. UNLESS the nurse also did an evaluation and management service which is recorded in the chart (more than just vitals taken) in which case you can bill a level 1 established patient visit (99211).

    See this link for when it is appropriate for a nurse visit to be billed as a 99211 -http://www.medscape.com/viewarticle/481337

  5. Default I can't pass the exam
    I have tried to take the exam for the 3rd time and I can't seem to pass the thing. I don't know what I'm doing so wrong. I don't know what to do? Does anyone have any suggestions for me?

    Should I be marking/highlighing in my CPT or ICD-9 book? I will take any suggestions anyone might have for me. I feel rushed always when I take it.

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