Internal Medicine Coding Alert

Question: I am auditing some of my physician's E/M visits, and discovered that he's not dictating a "physical exam" on the patient. He gives reason for the visit (i.e., vitals, past history, assessment and plan), but no physician exam notes on any follow-up patient. I'm pretty sure we need some type of documented physical exam (e.g., general mental status, general appearance, and orientation). When I discussed it with him, he says documented physical exam is not necessary for patients who are returning for follow-up appointments. Can I bill an E/M without the physical exam section filled in?

Alaska Subscriber

Answer: Your physician is correct. At a follow-up visit, the patient is an established patient, the codes for established patient office visits require only two out of three key components for a level of service qualification. In this case, you would code each of the medically necessary office visits with the appropriate choice for an established office visit from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) based on the documented history and medical decision making.