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The purpose of the visit is to review TMG results and discuss the diagnosis.

Luz Posted Thu 19th of September, 2019 11:23:29 AM
Please advise if this documentation supports and E/M service. "The purpose of the visit is to review TMG results and discuss the diagnosis. EMG showed widespread changes, consistent with MND. The patient did not have blood test before and apparently had blood tests today. And also had brain MRI and cervical MRI which were essentially non-contributory. The diagnosis is at this point …... Our research team is already dealing with the patient. Apparently, the patient made contact with Lambert and no appointment with the …..clinic but it will be done." I Spend 25 minutes all together. Thank You
SuperCoder Answered Fri 20th of September, 2019 08:03:45 AM

Hello Luz,

Thank you for your question.

 

If the reason of visit was planned, and the purpose was just to get the TMG results reviewed, then the documentation do not qualify for the E/M service; however, the above provided documentation states that the blood tests were done along with brain and cervical MRI, which were essentially non-contributory. If the above work performed was un-planned and the provider performed the service(s) on the billed date of service; then, the documentation qualifies for the E/M service.

 

Hope that helps!

Thanks

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