When entering the day's charges, the charge entry person notes that 2 vaccines were marked on the encounter form, but only 1 immunization administration code was checked. The office staff enters a code for the second immunization administration without first conferring with the physician.

What if only 1 of the ordered vaccines was administered (eg, 1 vaccine was on order and not available) on that date?

Next, the charge entry person notes that a preventive medicine service was marked on the encounter form and linked to the routine child health check and the otitis media International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. No other services were reported. The services are billed as reported on the encounter form.

What if the physician actually performed and documented a significant, separately identifiable evaluation and management (E/M) service to address the otitis media but neglected to report the problem-oriented E/M service...

You do not currently have access to this content.