Wiki No exam done, can E&M be billed???


Sacramento, Kentucky
Best answers
If my physician is seeing an established patient and no physical exam is done, can I charge an E&M visit? I have read in a couple places that even though you only have to have 2 of the 3, if an exam is not done, it's not considered a visit. When patient's come back for MRI results, the physician will forego the exam a lot. Any help would be much appreciated!!
Did the physician document his time spent with the patient? I read this awhile back that helped a lot and really gets into the bits of time based coding.

From the article..... CPT states, “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.”

Hope this helps!
This question has been debated a few times on this forum - you can probably find a number of older discussions over this issue. In my own opinion based on my reading of the guidelines, and based on my experiences and discussions with professional auditors who review E&M services, an exam is not required for an established patient if the other 2 requirements are met. I know other coders do not agree and would consider this a weakness and vulnerability in documentation. If your organization feels this way, it's something that is easily remedied by having the physician document a statement about the patient's general appearance, or record the vital signs, either or which meets the requirement of having something in the exam. This does add some strength to the documentation also because Medicare requires any covered E&M service to be a face-to-face encounter with the patient and if only the HPI and MDM are documented, there could be some doubt in an auditor's mind about whether or not this requirement was met.
Thanks everyone for the input!! My docs are ortho, you would think they would definitely do an exam being ortho but I have one that has gotten to where he's not documenting it on a lot of notes. I'm sure he's actually doing one, just getting lazy with his documentation as we are still paper.
I having doubt in this scenario....

Patient is a 26 year old female new to our group practice. She has symptoms indicative of gastritis with increasing abdominal bloating I have been contracted as a locum tenes to substitute for Dr. Allen while he is on vacation for two weeks.
Patient is a 26 year old female in for one month follow up to our group practice for asthma. My partner Dr. Jones is unavailable today and this patient is new to me. She has no new complaint and no recurrence of dyspnea (see previous note). Blood pressure 120/84, RRR, NBS, lungs clear to auscultation. All question answered. No scheduled f/u. Return PRN. The MDM was straightforward.
A. 99201-Q6
B. 99202
C. 99211-Q6
D. 99212