I know if the History cannot be documented due to patients condition, and if the doctor documents it correctly that he/she was unable to obtain a History and why, that we can give credit for a Comprehensive History. However, the exam is the exam, if you cannot document a portion of the exam due to the patient?s condition you cannot receive credit for it, you would have to bill based on time/counseling coordination of care, or on whatever OS/BA you were able to exam.
The guidelines themselves state:
-A notation of ?abnormal? without elaboration is insufficient
-Abnormal or unexpected findings of the exam should be described
-Brief statement or notation indicating ?negative? or ?normal? is sufficient
They are not stating negative or normal, and if it?s not negative or normal you need to give an explanation for the other. I always thought time was used, if you cannot document the proper elements for a given level, then the visit should be based on counseling and coordination of care and be documented as such.
How would they give credit for something that was not performed, not documented not done, correct?
Any guidance on this or information would be so helpful. Thanks in advance!
The guidelines themselves state:
-A notation of ?abnormal? without elaboration is insufficient
-Abnormal or unexpected findings of the exam should be described
-Brief statement or notation indicating ?negative? or ?normal? is sufficient
They are not stating negative or normal, and if it?s not negative or normal you need to give an explanation for the other. I always thought time was used, if you cannot document the proper elements for a given level, then the visit should be based on counseling and coordination of care and be documented as such.
How would they give credit for something that was not performed, not documented not done, correct?
Any guidance on this or information would be so helpful. Thanks in advance!
Exam: Unable to assess
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