Ex: A patient has an MRI done and comes in the office for the results, I get the diagnosis and a plan but no Exam. The report is very short so I can not pull from anyother section to get an E/M code.
Do I query the doctor, have them do an addendum, can I pull things from the intake sheet if they have dated/initialed it?
Any help is appreciated.
Thank you,
LLR
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How to code a report without an Exam