Wiki HELP!!! May be a stupid Question but I need an Answer

[jgarcia619]

If an MD documents a Detailed HPI and high complexity MDM, does this justify a 99233? No exam was documented in note. I guess what I am asking is, even though a follow up visits 99231-99233 only needs 2 out of 3 components, does an exam still need to be documented in note, or is a HPI and MDM enough? HELP please

 

[nrichard]

My $.02

It's my thought; that no he wouldn't due to the fact in the book it states 2 out of three components. I think this is due to the fact that specialties like psych, don't "examine" more than one area.

 

[nrichard]

Of course that's not to say that he doesn't need to document the exam.

If he did it, he needs to document but for coding purposes if, it's not there it's not there, and you can still code the E&M. I think you were overthinking this