nc_coder
Expert
I know that per CPT guidelines I am allowed to bill an additional E/M code with a routine physical if the visit goes above and beyond the normal routine care. However, the question is what is above and beyond a normal physical. I have a physician that will want to charge an E/M with the dx 401.9. This patient has been treated for a while for this problem. The same rx is renewed. No new treatment is done for this condition. What is the "additional work" that is required to validate the E/M? If someone could direct me to something in writing to present my case to my office, I would appreciate it.