Wiki Missing exam

[GAcoder]

What do you do when the entire exam is missing in established patient? How do you code E&M

 

[nnewton224]

Established patients only require 2/3 elements. I would use what is documented.

 

[GAcoder]

Established patients only require 2/3 elements. I would use what is documented.

Thanks that's what I do but I wasn't sure if anyone down codes for it. Doesn't seem right to give level 4 for comp hpi and det mdm and no exam.

 

[CatchTheWind]

On a related note: Can you extrapolate an exam from the impression? For example, if the provider omitted documentation of an exam, but noted in his impression that there are "multiple hypopigmented papules" on the scalp, I would think that you can count exam of the skin/scalp. Am I correct?