Wiki No exam done at appointment

[brenda long]

I have providers that put in their notes " No physical exam medically indicated"
They said they were told it is OK to do that. The guidelines say an appropriate exam and History is required.
Please give me your thoughts or concerns, as they are severely needed. Thanks!

 

[Orthocoderpgu]

E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed

 

[csperoni]

Exactly - an "appropriate" exam and history. It does not state required, but rather "when performed."
Full quote from the AMA guidelines:
E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes.

The provider has determined in their medical judgment that an exam is not needed to properly care for this patient.