Wiki E&M Documentation Rheumatology

[aadair]

I am billing for a rheumatologist who sees patients with osteoporosis. Patient will have a bone density study done, is an established patient and comes in for followup to discuss bone density results. Dr reviews bone density report, adjusts/renews patients RX's but does not do an actual exam. He wants to bill a 99213 and I explained he has to do an actual exam. He feels there is nothing to examine. Everything I read for 99212-99215 requires exam? He feels his time is worth something. Is this where time becomes the factor on the E&M used? Please advise and thank you!

 

[ARCPC9491]

I am billing for a rheumatologist who sees patients with osteoporosis. Patient will have a bone density study done, is an established patient and comes in for followup to discuss bone density results. Dr reviews bone density report, adjusts/renews patients RX's but does not do an actual exam. He wants to bill a 99213 and I explained he has to do an actual exam. He feels there is nothing to examine. Everything I read for 99212-99215 requires exam? He feels his time is worth something. Is this where time becomes the factor on the E&M used? Please advise and thank you!

If your physician doesn't choose to do an exam ... he may use the history and medical decision component. For established patients (99211-99215) only 2 out of 3 of the components are required. So if he feels no exam, then fine - but he has to document the history and medical decision making appropriately.
He can also use time as long as he documents the total face-to-face time. the time spent has to be 50% or more counseling/coordinating care.
Hope this helps!