Your exam would be whatever level of E/M the documentation supports, based on HPI, exam, and MDM. Depending on the amount of data reviewed by the provider, and whether or not there is an acute exacerbation of pain, your MDM will most likely fall in the low to moderate range. Again, review your documentation. If your office policy permits it, you may take information from the forms that are required to be filled out as well as the provider's dictation. In addition to the E/M, bill G0327, Physician service required to establish and document the need for a power mobility device, on the same claim (I'm assuming, of course that the patient is covered by Medicare.) You may want to check the CMS website to make sure that the provider has documented all of the information required to support this code.
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