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Wiki established patient with no exam

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blondie12

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I am coding with an internal medicine doctor and there were a couple patients they did a history and MDM but no exam...Can I still code this as appropriate? Thank you!!
 
I don't think so. How did he do MDM without doing an exam that was pertinent to the chief complaint? It also does not meet medical necessity.
 
exam

Remember, vitals count as a bullet on exam and so does appearance. If your provider saw the patient, there was some sort of exam. It would be interesting to know what the HX and MDM amounted to.
 
Don't forget that for an established patient visit, you only need documentation of 2 out of 3 key components. Sounds like your service would be billable.
 
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