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Reply with quote  #1 
On a new patient consult physician states:  physical exam deferred at this time due to lengthy discussion about the factor V Leiden and MTHFR mutations.  The lenghty time was not documented correctly so that cannot be used.

Because it is a new pt there must be a physical exam right?  Therefore, this is not a billable service correct?
mshay

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Reply with quote  #2 
Correct, without a physical exam or length of time documented this cannot be billed.
pjensen

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Reply with quote  #3 
Need a documented face-to-face encounter.  Even if the exam says, NAD that would be at least something.  I would ask the doc to go back and at least document the vital signs. That way you could bill for SOMETHING (level 1 new patient).  Or I guess you could conceivably bill as established office patient based on the MDM and history, but there must be evidence that a face-to-face encounter occurred.  PJ.
ecthompson

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Reply with quote  #4 
On a subsequent physical examination, I documented the following - 
Afebile, BP - 222/93 P-59 Sat - 95%
Lungs - clear to A and P
CV - RRR
Abd - soft, nontender, positive BS, no hepatosplenomegaly
Neuro - opens eyes, follows commands, nonverbal, alert, oriented - ?, moves all 4's

So, I thought I wrote a detailed physical exam. My coder says that I need 2 bullets from 6 different organ systems. I said No, I needed 12 bullets from any organ system. Am I right or did I screw up?
pjensen

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Reply with quote  #5 
Using the 97 rules there are TWO options to qualify for a detailed exam: EITHER you can do two bullets from six organ systems OR you can do do a TOTAL of 12 bullets pulled from at least two organ systems (I never even mention the fact that they have to come from two different organ systems because it is impossible to get 12 bullets from any ONE system).  So you do NOT need six organ systems if you use the alternative approach.

Having said that, I can't find 12 bullets in your exam using the general multisystem exam.  I only count seven or eight.  Which bullets are you using?  Are you using a specialty exam?

The quote from the 97 guidelines is below:

 

Detailed Examination – s

hould include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (&bull is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (&bull in two or more organ systems or body areas.
ecthompson

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Reply with quote  #6 
Thanks for your reply. I was also confused about these bullet points. I'm clearer on it since I downloaded your audit template. 

I appreciate your time. 

Thanks!
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Reply with quote  #7 
I would like clarification of the statement by pjensen, that it would be possible to code the New patient without a documented exam as an Established patient.
I was taught that a "new" patient" can only be billed with a new patient CPT code. If the criteria is not met, then it can't be billed.
livcyxing

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Reply with quote  #8 
I would like clarification of the statement by pjensen
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pjensen

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Reply with quote  #9 
Sorry, can't give you a citation, just my opinion that if there is evidence that there was a face to face encounter, the physician should be able to bill for something using the key components which were documented.  Could be wrong.  PJ.
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Reply with quote  #10 
Can anyone tell me if you can take part of the exam from the hpi? I have a progress note that no exam was done but at the top of the note there is the const. readings. I thought that in order for this to be part of the exam in needs to be under the exam part of the note. I am being told that the exam can be taken from any where in the note. Thanks!
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