Wiki RadOnc consult no physical exam

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Tonyj

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Pt was referred to a radiation oncologist for consultation before an upcoming surgery to his prostate gland. A comprehensive HPI was dictated as well a moderate medical decision making level. The problem is the physical exam was deferred at the pt's request. What level could be billed? The physician wants to bill a level 99203 but how without a PE?
 
Two thoughts here. One - for a situation like this, maybe time based services would be better suited, provided the documentation supports that. Second - you could still get a 99201 for a PF exam if the doctor at least recorded vitals and/or general appearance for the constitutional exam element. Even if the patient refused the rest of the exam, if the doctor at least documented the general appearance, you can get a PF exam with that.
 
Lance correct with caveat

Lance is correct that time could be used, (if it were documented) and only if the documentation supports the medical necessity of the exam not being required. Otherwise I also agree with GA Peach that the vitals could be used to help support at least a level 1. On a side note, I hope that Rad Onc isn't planning radiation treatment without a patient exam :confused:
 
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