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Wiki No Exam component documented

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millbj

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Need help/advice:

I have a provider who is seeing est. pt's back for f/u in office so 2/3 I know. But he documents no exam on these pt's..only a History & Assessment Plan. Is this ok? I feel it's not best practice but would an insurance auditor or any auditor let this go and only code off the History & MDM?

Thoughts/suggestions any/all appreciated.
 
Compliance Auditing Perspective

From the compliance auditing perspective, a history and MDM is sufficient documentation to support an established patient E/M code. I do question, though, whether or not there are ancillary notes that may support vital signs or appearance and could be calibrated to flow into the note. Does the physician document any hands-off exam elements (A&O, gait, speech pattern, etc.)? The elements don't have to be sectioned off by bullet points or bold font to count as an exam if they are documented. An auditor would look for these elements elsewhere in the note before ruling them out.
 
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