Forum - Questions & Answers

Nov 13th, 2013 - ssgillMD

History/physical coding

If a patient comes in for evaluation of a skin lesion and I do a complete h/p due to my EMR. If I wait and take off the lesion on another day can I still bill them for a Level 4 office visit due to the complete h/p?

Nov 13th, 2013 - nmaguire   2,606 

re: History/physical coding

I doubt it, given your explanation. Why would it be medically necessary to do this high level for a skin lesion? Your EMR does not dictate the level of service, medical necessity does. You can write a book but can only bill what is medically necessary based on the presenting problem(s).

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