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Wiki Established pt exam

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bedforak1

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Nashville, TN
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Hello,

I recently encountered a provider that was seeing patients but not documenting an exam. His argument was since they were established patients and me met two out of the three componemts he should get credit for his coding. I have never heard this. Can anyone shed some light? Thanks
 
If the documentation that is there is appropriate for the visit reason then yes this can be done. We have providers that will document the HPI and Assessment/Plan for mental health type issues where an exam is not necessary to evaluate the issues at hand. But if the provider is trying to do this for lets say an URI or leg pain then no, this would not be appropriate as an exam would be necessary to evaluate the issues.

Hope this helps.
 
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