# RE:visit/No exam



## cynthiaj54 (Apr 14, 2008)

*RE:visit/No exam*

One of our physicians saw a patient, spent about 20+ minutes taking a history and then the patient refused to be examined.  Stated she had another appointment to get to. Insurance is medicare.  How can she bill this? Unlisted code?
Thanks so much


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## rthames052006 (Apr 14, 2008)

cynthiaj54 said:


> One of our physicians saw a patient, spent about 20+ minutes taking a history and then the patient refused to be examined.  Stated she had another appointment to get to. Insurance is medicare.  How can she bill this? Unlisted code?
> Thanks so much



What do you have for history and MDM... I would make sure the physician documents  that the pt "refused" or left prior to the exam... 

Now maybe I am assuming here but maybe he didn't get to MDM.  If that is the case I would submit to medicare with the unlisted code and the documentation.

Good luck,


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## ashack63 (Apr 16, 2008)

*Exam refused*

If the provider sat there for 20 minutes, did he not notice the constitutional of the women ? Pleasant, well nourished, well developed, obese, agitated ?
Did he not determine her psych - alert to person, place, time, Memory intact, poor historian - ?
These are 2 areas of exam for 95 guidelines, and if documented count just as much as hands on exam. Musculoskelatal - normal gait and station, 
So if HPI, ROS and PFSH were included in his 20 minute history, Exam documented with what he observed, and MDM straightforward - What she presented with, there is an evaluation code, as only 2 out of 3 need to be met for MDM. In the ED, we have many patients who leave before tests are run, or RX - treatment plan are written, patient decides they don't want to wait any longer. Th esigns and symptoms are the primary DX, with Non-compliance as supplimental code
If you go to a restaurant and order appetizors, eat them and then decide your main course is taking too long - do you get to leave without paying ?

Of course - all the above needs to be documented !


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