No exam

How do you go about coding an initial visit note when the patient refuses to let the doctor exam them and there isn't any time noted in the note? Doctor stated under the exam section- patient refused to be examined

Why not

ask the doctor to write an addendum with the time spent? As long as the doc dates and times the addendum it is legal. Or she gets paid the lowest level visit.

no exam

Time, if the visit meets the criteria based on time.

To get a low level E/M:

NAD, alert and oriented gets you a level 2.

I know this doesn't reflect the work the physician did.

Exam

This will pretty much be determined by payer on review. But, If exam element(s) states “Refused” or otherwise makes it clear that the physician intended to perform the exam but the patient could not tolerate because of pain or refused to cooperate due to mental or emotional issues or could not cooperate due to health issues or age, credit should be given for the element, as would be medically necessary. If patient refuses the entire exam, credit should be given for exam. Documentation must support patient's refusal and reason given, and that the physician intended to perform the service.
Again, as coding is so subjective, it will be in the eyes of the beholder.