SAMPLE NOTE – ONE NEW SYMPTOM (HEADACHE) ADDRESSED THOROUGHLY
CC: Headache
Had for several years, a little better with OTC meds, L side, throbbing, usually lasts 5-10 hours, 2X/mo, no aura, + n/photophobia, neg CT
PE: NAD, neuro nl
A: Migraines
P: triptan prn (whichever one)
RTC 1 mo.
This bill includes an example of an extra long conversation between the physician and patient to discuss a long list of diagnostic and treatment options. The ET code is for the extra time spent over a more typical thorough assessment of chronic migraine headaches.
Patient Bill
| Issues Addressed |
Thoroughness | Code | Allowable Charge |
| Migraine | THOROUGH | IA.3 | $45 |
| IM-CP.1 | $3 | ||
| ET-SD.9 | $45 | ||
| Total | $93 | ||