When a current Medicare patient on Maintenance comes in with a new injury, do we have to do an exam? If yes, what E/M code should we use for an established patient?
A.- Yes, you must do an updated evaluation (history and physical exam) to manage the condition. Your documentation will suypport the status for the new injury/condition, with a new start date for restorative treatments. Select an appropriate E/M code based on the E/M key components. Once the patient reaches Maintenance care again, discuss it with them and use the ABN, which is their acknowledgement and declaration of their return to Maintenance care.
