# Exam refused by patient



## cwilson3333 (Jun 3, 2013)

Can this visit be billed?  Medicare patient in Assisted Living brought to office.

CC:  Right wrist fracture
HPI: The patient is 84 year old brought in for evaluation of wrist fx that occurred 
       5-21-2013. Seen in ER and had CT of CSpine as well as head, which looked okay.
       Facility she is at reports she has not been able to keep splint or wrap on hand and 
       she messes with whatever is put on and tries to get it off.  Has a bulky dressing on 
       today.
PE:  General appearance; WDWN femal in no acute distress
       Musculoskeletal: She does not want to be examined; refuses to remove Ace wrap.
       Very upset and wants to leave office. The aide who brought her in says she has not
       been like this in past. I [the physican asst] contacted son and daugher by phone.
       Daughter said she was like this when they took her to hospital.
Orders:  Xrays of LS showed some degenerative changes and spondylolisthesis.
             Xrays of wrist show comminuted intraarticular fx of distal radius and ulnar
             styloid.
Assessment: Comminuted intraarticular fx distal radius and ulnar styloid.
Plan: We went over tx options, including conservative care and the fact that there would
         be a clinical deformity, loss of ROM vs rights of surgery or closed reduction. She
         [the aide] will discuss with the brother [who is physician] and figure out what they
         want to do. If they would like her seen, we would be happy to see her back.
         The aide was given a Velcro spint to try on her.
Again, no examination was done.

Signature of physician assistant


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## MnTwins29 (Jun 3, 2013)

You do have a constitutional element for the exam (General appearance), therefore you have all three key elements documented and can bill accordingly.


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## mitchellde (Jun 3, 2013)

true you have a focused history due to the brief HPI, and a focused exam, and a straightforward decisionmaking,  you could even say low complexity decision making but it would not make any different whether this is a new patient or established patient.


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## schargis01 (Apr 10, 2015)

*Exam must be documented in correlation to HPI*

Many auditors are denying payment for situations where the exam element relating to the HPI has not been documented so general would not be acceptable for the situation with many payers.


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## LLovett (Apr 10, 2015)

*Can you provide a reference to this?*

"schargis01	
Exam must be documented in correlation to HPI
Many auditors are denying payment for situations where the exam element relating to the HPI has not been documented so general would not be acceptable for the situation with many payers."


Do you have any specific references to this?

I have never seen an auditor kick on something like that, and myself as an auditor would not do so either. This seems to be more of a clinical judgement that a peer-to-peer review might turn up, not a coding call.

Thanks

Laura, CPC, CPMA, CPC-I, CANPC, CEMC


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