Q #8: A doctor bills both preventative and office visit. The problem is, my son was a patient and I was in the room. There is NO way both were done and NO way they could have enough documentation to have separate notes. Do I say something?
A: Laureen: I would ask for a copy of the documentation. Sometimes, they can pack a lot in a small amount of documentation in a small amount of time, but I mean you’re a coder you know. If you brought him in for a well visit and you don’t mention it was a problem addressed. If they could do a history and exam and a medical decision making blip in addition to the preventative visit note, then it’s possible you could have both. My rule of thumb is, my little rhyme that I teach is, if you don’t have a HEM, you can’t bill an E/M – meaning a regular E/M. So, I’d ask to see the documentation. If you want to email it to us we’ll take a look and put our vote on it.
Alicia: Don’t tell ‘em you’re doing that, though
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