Question, isn't the assessment and plan a part of the chart notes?
There doesn't necessarily need to be an exam for each diagnosis, but there should be a documented (in the notes) assessment and plan for each diagnosis addressed. Example, there won't necessarily be an exam for diabetes, but the A&P may state "DM 2 well managed with current medications, new rx given for metformin and test strips". In this case diabetes would count toward the MDM for the visit.
But, if the A&P just states "E11.9 - Type 2 diabetes mellitus without complication", this would not count toward the MDM because there is no actual assessment or plan, just a statement that the patient has the condition.
Jonique Dietzen, CPC