I would recommend that you do an actual e/m audit of the note and then "suggest" to the physician that the notes support a level "whatever you come up with"... then support that with your audit.
However, the fact that he's billing the additional code with it does not seem surprising to me - but you may need a modifier on your E/M.
Those G codes are paid at "carrier discretion". Is this a Medicare patient? The note needs to also reflect that a "personalized prevention plan of service (PPS) was provided for the patient.
Whatever you do - DO NOT just change the code before consulting with the physician. It is the physician who is assigning codes - however, the coder should be assisting in making the physician aware of the documentation.
I hope this makes sense and is helpful. ?????
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