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Family Practice Coding Alert

You Be the Coder:
Confused About Reporting Incomplete Annual Exam? Here's What to Do

Question: A 16-year-old girl presents for a well-child preventive medicine service with a school form that she needs filled out for sports. The nurse takes the patient’s measurements and vitals. Our physician performed a routine history and provides age- appropriate patient education. But when our clinician tried to perform the physical, the patient refused to be examined. After our physician informed the waiting mother [...]