# abnormal mammogram



## daniel (Jun 10, 2008)

My question to you all, how would a physician document a follow up on a abnormal mammogram??? To justify a level of service for a E/M.

Respectfully

Daniel
CPC


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## Kris Cuddy (Jun 23, 2008)

Daniel,

After an abnormal test result, if the physician must physically see the patient due to the abnormality, then the documentation would reflect the abnormality, the review of the study and whatever else would be medically necessary. Medical necessity is the over-arching criteria for evaluation and management services, so all documentation should be based upon that necessity for the particular patient. Using the three key components, history, exam and medical decision making, a level may be selected.

However, if the patient is coming back in after an abnormal mammogram because the physician is needing to discuss the diagnosis/results and determine what the next step should be and establish a plan, then time may be the key component used for the visit. The provider must document/summarize the discussion of prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction, or discussion with another health care provider. The total time must be documented, the time spent in counseling and/or coordinating care must be documented, and the content of the counseling and/or coordinating care must be documented. If these are all present, time may be billed as the controlling factor.

In a whole separate train of thought, and just my two cents here, if your concern is medical necessity (I'm uncertain of that just based on the post) I would advise the provider that if the patient did not really need to come back in and the provider is hoping to come up with another avenue of income, to not schedule this type of appointment.

Kris


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