Wiki How to code a report without an Exam

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LLRodgers

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Can anyone tell me how you get an E/M code for a report that has no exam section.

Ex: A patient has an MRI done and comes in the office for the results, I get the diagnosis and a plan but no Exam. The report is very short so I can not pull from anyother section to get an E/M code.

Do I query the doctor, have them do an addendum, can I pull things from the intake sheet if they have dated/initialed it?

Any help is appreciated.

Thank you,
LLR
 
If they simply took the patients vital that would be considered 1 body area or system - that would give you a problem focused exam.
I believe a plan would make it at least a straight forward MDM.
If this is an established patient you have a 99212.
 
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