• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Documentation of physical exam

Create Wiki
L

LauraLight

Contributor
Messages
12
Location
Rock Hill, SC
Best answers
0
Hello! We are all aware that the extent of a physical exam is no longer considered in choosing an E/M level for coding. However, it is still my understanding that CMS expects that an exam be documented in order to have a complete note, and be reimbursed as a medically appropriate and necessary visit. We of course cannot decide how extensive an exam should be; That is left up to the provider to determine based on their own medical and professional judgement. However, it has always been my understanding since the expiration of the 95/97 guidelines that an exam still should be a component of the visit, just no longer used to determine code level.

Does anyone have any references from CMS/Palmetto GBA or AMA handy that they could share? I have researched this recently and found it is still needed, but strangely cannot find it while I am reviewing my research, now. Thank you, all!
 
You must log in or register to reply here.
Top