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Deferred Exam-I ran across


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I ran across an E/M service where all the elements met level 3 except for the exam. There were 5 "bullets" and the rest of the exam was deferred due to the patient's condition (on oxygen, advanced COPD, trouble with ambulation). Can I still code this as a level 3 visit? I have in the back of my head that a deferred exam does not throw off the entire e/m level, but I cannot find the exact reference. Does anyone know how to set me straight?



True Blue
Hibbing, Minnesota
Best answers
If this is for physician office coding - Level three, only 2 of 3 elements need to be met so if you have at minimum an EPF HISTORY and LOW MDM - and no EXAM, it still meets requirements for a level 3 ESTABLISHED patient 99213; however, for NEW patient Level 3 - you'd need to have ALL THREE elements, those being; DET HISTORY - DET EXAM - LOW MDM to equal a 99203 new patient level 3.
oops, forgot to add - reference to this is right in the front of the CPT manuals, under the Evaluation and Management area - it'll tell you what's needed for each level.