Networker3412
Networker
We have a difference of opinion in my office and i need documentation to back this up. Am I correct that you cannot code any E&M level if the physician does not document that an exam was performed? He did not mark any organ systems or anything therefore you cannot code a level correct? my second thing Is it legal to query the physician about whether or not he did an exam and to document it?
I have given the CPT book to my coworker about not being able to code a level when the exam is not documented however he says we should not be sending this back because its illegal. I was taught it is ok to query a physician???
I have given the CPT book to my coworker about not being able to code a level when the exam is not documented however he says we should not be sending this back because its illegal. I was taught it is ok to query a physician???