E/M Level

KimmHall

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What level E/M can be billed if no physical exam has been performed but comprehensive history and and medical decision making of moderate complexity? Can anything higher than a 99211 be billed with no physical exam?
 

KimmHall

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What level E/M can be billed if no physical exam has been performed but comprehensive history and and medical decision making of moderate complexity? Can anything higher than a 99211 be billed with no physical exam?

I need to pose this question differently after speaking with the physician. the patient is in the office for a follow up visit. No physical exam was done, a comprehensive history, and medical decision making of moderate complexity. There was also more than 50% of the time spent with the patient (25 of 35 min) in couneling. I am having some diffuculty rationalizing the "no physical exam". Any input on what level this should be is appreciated.

Thanks
 

RGALVEZ

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Since you say that the pt is coming in for a "Follow Up" visit we can assume this is an established patient. Given that you also said that he spent 25 minutes of a 35 minute visit on counseling, I would code based on time. That would give you a 99214. This of course requires documentation of the time spent in counseling. This is based on the 1997 E&M coding guidelines.
 

Karolina

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I agree with Ray. In the case of an established patient you need to have 2 of the 3 key elements. Not having an exam still gives you history and MDM (these are your two elements). There are times when an exam may not be medically necessary or the patient disallows it and that's ok (we are talking about an established patient).
Now, if counseling is dominating the visit and time is documented you don't even have to worry about any of the key elements and their levels. The provider must document the time spent, that more than half of it was in counseling and elaborate on what the discussion was all about.
Of course, a chief complaint is always required.
 
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