Wiki Medically appropriate history and exam??

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andepow

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Hello all!

I'm relatively new to medical coding and I've been trying to learn my way around E/M coding. While doing some practice questions, some questions specify what type of history and exam the patient had. Some don't. Some just say the history and exam was "medically appropriate". I am not sure what that means. Here is the question:

Dr. Smith's patient comes in with borderline obesity. He performs a medically appropriate history and exam. He spends 30 minutes discussing the risks associated with obesity. He prescribes diet and exercise. What established patient office evaluation and management code is reported?

a. 99212
b. 99213
c. 99214
d.99215

Could someone please help me understand? Thanks in advance.
 
It means the provider performed a history and exam that was appropriate in detail/content for the patient's presenting problem. You don't need to be concerned with that as far as the 2021 E/M guidelines are concerned. They did it and it was 'appropriate'.

What matters is either time or MDM. Judging by the documentation you submitted, this would be a 99214 for 30-39 minutes of time.
 
twizzle said:
It means the provider performed a history and exam that was appropriate in detail/content for the patient's presenting problem. You don't need to be concerned with that as far as the 2021 E/M guidelines are concerned. They did it and it was 'appropriate'.

What matters is either time or MDM. Judging by the documentation you submitted, this would be a 99214 for 30-39 minutes of time.
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Thank you very much for replying!
 
What happens in the case that the doctor says an appropriate exam was done but the note does not reflect the exam documented. Would you query or does it not matter since it is noted a medical appropriate exam was done.
 
When it comes to exams, it ALWAYS comes down to this: "If you didn't write it down, you didn't do it." That was drummed into me every single year in Optometry school and by every malpractice and record keeping class I've taken since graduating.

Even with the relaxed history and exam criteria, it still comes down to standard of care when evaluating and treating patients. If what's documents doesn't meet that standard of care, IMHO, the provider hasn't met the code criteria.

Tom Cheezum, OD, CPC, COPC
 
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