Wiki office visit with no examination

[t.b.townsend09@gmail.com]

What level visit can be billed if the ros is done and hpi and mdm is there but no exam? I think it should be level 99212, anyone else think there is justification for a higher level?



thanks.

 

[Pathos]

Hello,

It would be difficult to determine the correct E/M level without additional information/the patient chart.

But first, let me leave the CMS E/M guidelines as a gold standard for your reference.

Depending on how many HPI and ROS elements and MDM documented, which would determine the overall E/M level. Were there any Past Medical/Family/ Social History documented? Since the E/M level could range from 99212-99215 depending on what other elements documented, and the overall Medical Necessity.

 

[t.b.townsend09@gmail.com]

my question is then could you bill a level 4 with no exam done at all? yes the mdm is there and the cc and pfsh are also documented as well as the ros.

 

[Pathos]

You can bill an Established Patient visit without a Physical Exam, since only two of the three E/M components (History, Exam, MDM) are required for 99211-99215.

 

[t.b.townsend09@gmail.com]

Thats what i thought just wanted to double check.ty