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Wiki 99201 - Required exam

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maranieves

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All 3 componants of a 99201, a problem focused history, a problem focused exam and straightforward decision making, must be met in order to code a 99201. If a new patient presents due to late menses what exam is required. Does this mean that a pelvic exam must be done? I'm getting mixed information as to whether it there only needs to be 1 organ or body system examined or if it has to be te affected system or body area.
 
In "real" time...

I have not seen an exam that did not included the affected area, as long as the patient mentioned a specific problem. In the strictest sense, the guidelines don't seem to help and I don't see why one other area may not be included (especially if constitutional, such as the only documentation being vitals and general appearance), but I have not seen this in my many years of E/M reviews.
 
It would be unusual to have a CC and then a diagnosis for a problem but no exam of the affected area. If I were an insurance carrier and audited the chart, medical necessity would be the major question. There is a defined problem but no exam so why are you seeing the patient?
 
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