99231 rounding visit.

MEZIESKY

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When our Dr. round on patient does there need to be a exam everytime. The may be checking to see how the patient is feeling and my go over test results or my order test. I work for general surgery dr. They consult the patient and if they do not need surgery at that time the may order test and check on the patient they next few day. When i look at the 99231 it says must meet 2 of 3 components. We have recently hired a outside auditor to come in and evaluate our coding and billing. She has stated that 99231 must include a exam every visit. Any thought would be greatly appreciated.
Thank you
MG
 

thomas7331

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This question has been debated a number of times on this forum and different coders and auditors have different views on whether or not an exam is required when only 2 or 3 components are needed for a code. It's interesting to hear you say that an outside auditor told you this because at the facility where I used to work, we had an outside auditor tell us exactly the opposite. Personally, my interpretation of the guidelines is that an exam is not necessary if you can meet the code requirements with the history and MDM, but if your organization decides to require it to protect itself from the possibility of an unfavorable audit, it's a very easy fix for the providers since they could simply document a review of the vital signs or general appearance of the patient to meet a constitutional system PF exam which would make the question a moot point.
 
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