Wiki EMR wording

[Andrea828]

I have a client with an EMR system that has specific wording for return visits. The doctor is insiting that if the chart note states to Return in One Month "for..." instead of "with...", then he can't bill for an office visit at the next visit. Is this true or it doesn't matter whether it says with or for?

 

[ehanna]

I have a client with an EMR system that has specific wording for return visits. The doctor is insiting that if the chart note states to Return in One Month "for..." instead of "with...", then he can't bill for an office visit at the next visit. Is this true or it doesn't matter whether it says with or for?

This is a pretty general statement. I think the content of what they are returning for (with) dictates whether he can bill a level or not. Example: Pt comes for lab review and says "oh by the way" I have this skin lesion. Doctor looks at it, determines it should be removed and they schedule an appointment for the removal. At removal time the only charge should be the excision.

If Doc says labs are fluctuating and we will return in a month "for" a recheck then he is continuing treatment of an ongoing problem. An office level should be charged. A follow up code might be in order but it is a problem oriented visit.

There are lots of reasons why a patient should return "for" or "with" and the reasons would dictate whether a level can be charged. Those two words should not be a determining factor of deciding which level (or no level) to charge.

I hope this makes sense