IN Need of E/M Expertise

Bellaboo

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NP sees patient, documents a detailed History, Mod MDM, no exam- not even vitals
there is no time noted, so can not code based on time. Since there was 0 exam done
would this be a 99214 or can it not be coded since there is not a single exam element
documented. Yes 2/3 required but even a problem focused exam requires at least 1
element and this has zero. Can it be coded?
THANKS!
 

LLovett

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Yes, if this is an established patient

Exam is not required for established visits. If this was a new patient I would bill it as an unlisted code, 99499.

Laura, CPC, CPMA, CEMC
 
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