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tci Part B Insider - 2014 Issue 28
Part B Mythbuster: Lack of Symptoms May Not Sink Your E/M Claims
No pain? You may still gain.
Myth: You can’t bill an evaluation and management claim unless the patient has pain or some similar complaint.
Reality: Sometimes you’ll find that test results are what prompt a patient visit, not pain or even a complaint. A patient may come to a specialist or other physician because he or she has abnormal test results.
Challenge: It can be a challenge to obtain four out of eight elements of the history of present illness (HPI) when the patient comes in with severe anemia, for example. The patient may say something like...
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