Here , Do we need to use modifier with E & M codes over here depending on the type of appointment ? If yes Which ?I mean as per my knowledge, 95 modifier with CPT code for commercial insurance plans, while the “GT” modifier must be included for Medicare and Medicaid plans is used. Request to guide the importance and requirement of these modifiers and effect on payment.

Chief Complaint
None recorded.
Vitals
None recorded.
Allergies
Allergies not reviewed (last reviewed 12/13/2018)
Medications
Medications not reviewed (last reviewed 12/13/2018)
Flucelvax Quad 2018-2019 60 mcg (15 mcg x 4)/0.5 mL IM suspension
12/08/18 filled MEDCO
predniSONE 50 mg tablet
10/26/18 filled MEDCO
Vaccines
None recorded.
Problems
Reviewed Problems
Family History
Family History not reviewed (last reviewed 12/13/2018)
Social History
Social History not reviewed (last reviewed 12/13/2018)
Smoking Status: Never smoker
Surgical History
Surgical History not reviewed (last reviewed 12/13/2018)
Appendectomy – 08/2001
Past Medical History
Past Medical History not reviewed (last reviewed 12/13/2018)
HPI
Pt here for 2nd visit to discuss condition and develop a relationship. We discussed the above and future use of medical marijuana.
ROS
ROS as noted in the HPI
Physical Exam
Patient is a 25-year-old male.

Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: NAD. Ambulation: ambulating normally.

Psychiatric: Insight: good judgement. Mental Status: active and alert and normal mood. Orientation: to time, place, and person.

Head: Head: normocephalic and atraumatic.

Eyes: Lids and Conjunctivae: non-injected and no discharge.

Neck: Neck: supple and trachea midline.

Skin: Inspection and palpation: no rash, lesions, ulcer, induration, nodules, jaundice, or abnormal nevi and good turgor.
Assessment / Plan
Pt here for followup visit. We discussed patient’s future use of MMJ. We discussed the risks and benefits. Pt understands that we will certify patient, but the recommendation does not constitute a prescription for medical cannabis.

Pt here with below diagnosis – pt here for evaluation for their condition, evaluation of their medication use, and discussion for alternative treatments.

1. Multiple sclerosis
G35: Multiple sclerosis

Return to Office
None recorded.