Wiki No exam documented for established patient visit

[dgerry]

For an established patient visit you only have to meet 2 out of the 3 components to determine the billable level of service - BUT - is it okay to completely skip documenting any physical examination and still bill an E&M based upon the history and medical decision making? Thanks for your help!

 

[MnTwins29]

I have seen this and haven't had a problem with doing this, BUT.... were there ANY exam elements documented? Were the vitals done by the nurse and reviewed by the MD? Was a statement made about the patient's general appearance, mood, etc? You might be able to get a constitutional exam element and therefore get a problem focused exam.

Don't forget about time-based as well, as long as that is documented as well.

 

[kathymoon]

It is possible. I would think you would at least have constitutional elements. Example, if a patient is seen for depression, there may not be any actual physical exam but the time counseling should be documented.

 

[MikeEnos]

If there is no exam, there's a good chance that you can select the level of service based on Time being the controlling factor of the visit. Your provider must document A) The total length of the visit, B) that greater than 50% of the visit was spent face to face with the patient and/or guardian(s) counseling the patient and/or coordinating their care. Lastly, C) the note should give an indication of what was discussed (usually it's in the assessment and plan.)

If they do this, they can select the level of service strictly based on time, completely independent of the 3 key components. No exam required. However, there should be medical necessity for an evaluation and management service to be billed.