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For a subsequent visit, only 2 of the 3 components are required. But does the physician have to perform an exam on his note?
For a subsequent visit, only 2 of the 3 components are required. But does the physician have to perform an exam on his note?
I have to disagree with your answer Brandi.
On established patients exam is not a required element. If they do the exam, yes they have to document it. But they only need to do the exam if it medically necessary. So there will be times when no exam is done or documented and that is perfectly acceptable.
Laura, CPC, CPMA, CEMC
For a subsequent visit, only 2 of the 3 components are required. But does the physician have to perform an exam on his note?
To much Jay Leno... wanting to have some fun... how would the physician perform the exam on his note? So sorry...
Seriously now…
II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION
The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:
• reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
• assessment, clinical impression or diagnosis;
• plan for care; and
• date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating and/or consulting physician.
5. Appropriate health risk factors should be identified.
6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
What does the punctuation mean?
The reason for the encounter must be documented
The relevant history must be documented
The physical examination findings must be documented
Prior diagnostic test results must be documented
OR – does it mean
The reason for the encounter must be documented
The relevant history must be documented
The relevant physical examination findings must be documented
Prior diagnostic test results must be documented
The punctuation demands the first case: The physical examination findings must be documented.
If there is no examination, the examination can not be documented.
Almost always there is some form or examination. The nurse may perform the physical portion of the constitutional exam (weight, blood pressure, respirations); the provider performs the appearance portion of the constitutional exam…
There are five levels of care for this type of encounter which all require documentation of TWO out of THREE key components. Key components are those components that are medically necessary to determine the appropriate plan of care.
Only the provider can determine if a physical examination is medically necessary to determine the appropriate plan of care.
#3 represents the only exception to the usual Key Components rules: the 'time' controlled visits. What I take from the requirement, is:Irrelevant Side Note:
I have an odd way of remembering how to choose the highest possible level of new vs. established E/M's. I think that college grades are a good analogy to explain it.
Imagine a writing class that, has 3 major assignments, and one written exam; all three assignments will be graded on their own merits, and taken into consideration for the final grade for the semester (the test, like nature of the presenting problem, doesn't count toward the final grade) - the final grade will be limited to the lowest grade achieved on any one assignment; and if any assignment is not completed, you will fail the class. That's how the key components contribute to an overall code assignment for a new patient code.
Now, imagine that same writing class, except you have a much more relaxed teacher, who says that you'll be allowed to drop your lowest grade, and your final grade will be determined by the lowest of the 2 remaining scores; you'll still fail for an incomplete assignment.
That's like established code requirements. Here's another example: take an encounter with a Comprehensive Hx, Det. Exam, and Low MDM, see how it's applied to this method to demonstrate how the requirements differ from new to established E/M levels: For new patients, if the lowest score determines the overall code, it's limited to 99203 - since all 3 levels must meet or exceed the required level (stated in the code description) to select the code, the lowest level achieved limits the overall code selection.
To determine the highest level code attainable through established requirements, I'd drop my lowest 'grade' (That Low MDM) from consideration, then code the lowest of the remaining 2 'grades', which is Detailed, in this example - resulting in 99214.
I still disagree with stating no exam no established visit.
WPS is my carrier and I actually have a practice that was audited (prior to my employment) and fined by the OIG on E/M. I am extremely comfortable in saying that this was not an issue when they looked at E/M services and the practice in question does not do exams on established patients due to the nature of the problems they treat and they are not billing based on time either.
Just my experience for what its worth,
Laura, CPC ,CPMA, CEMC
As I mentioned, it's a regional thing - our MAC (Trailblazer) has stated that it wouldn't be counted, and so as WPS Medicare, but other MAC's may not be as strict in their interpretation - there's a reason it was hard to find consistent information from the carriers on it - there's not a consistent stance. This is one I don't mind disagreeing with you on, because I think it's one of situations where there's really not a 'right' answer - just what's right for where you live. That probably accounts for why Trailblazer's CERT errors were identified in over 90% of the claims reviewed, compared with other regions that had a much more reasonable error rate - they're scoring us harder, than even the OIG would. I appreciate the different perspective!
I agree.... To determine the level only two of three are required … if you have a problem focused exam and comprehensive history and moderate medical decision making, you have an exam but you do not have to consider that it was only a problem focused exam to determine that you can bill a 99214 based on medical decision making. In the same way, if you have a comprehensive exam and history, but the medical decision making is problem focused (unless the history and exam were medically necessary to determine that the medical decision making was problem focused, which in the case of an established patient would be the exception rather than the rule) a 99215 could not be reported because the comprehensive history and exam are not medically necessary. I love E&M's.