Wiki Making sense out of a 99213

[GretchenC123]

Can someone please clarify. Can a provider exclude a physical exam when billing and coding for a 99213? I am auditing a record and the provider treated a patient for nearly 2 years and only documented one exam in November 2021 and never documented another physical exam again despite 13 repeat visits, all coded as a 99213, with the last visit being June of 2023. Is this acceptable and would these claims be adjudicated?

Thank you.

 

[Cheezum51]

As the old saying goes, "If you didn't write it, you didn't do it." How can someone continue treating a patient over that many visits without doing and documenting some type of exam? Those claims would be rejected in a review IMHO.

Tom Cheezum, OD, CPC, COPC

 

[GretchenC123]

As the old saying goes, "If you didn't write it, you didn't do it." How can someone continue treating a patient over that many visits without doing and documenting some type of exam? Those claims would be rejected in a review IMHO.

Tom Cheezum, OD, CPC, COPC

Right? This is a personal injury claim which points to suspicious behavior. I see it all the time. However, I have never seen such blatant disregard for the standard of care. It seems like the requirements about a physical exam are vague though. Thanks.

 

[csperoni]

It does seem highly suspicious. While I am not a clinician, I would think for an injury that an exam (even occasionally) would be required.
However, from a purely coding perspective, an exam is not required and is to be determined by the clinician. From the AMA guidelines:
►E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes.◄
If I were the auditor, I might query the physician about it, but if the physician stated "In my medical judgment, an exam was not necessary and I did not perform one.", it would not mean 99213 was not met.