Physical exam documentation

[shruthi]

One of our provider is not documenting Physical exam for face to face visit, only the vitals are documented. Even though 2021 E&M guidelines are based MDM and Time, as per compliance/documentation perspective is it necessary to have the Physical exam documented or only vitals are sufficient.

 

[Orthocoderpgu]

Re-read the 2021 E/M documentation guidelines and note the words "when performed". The extent of the history and exam are determined by the treating provider.

 

[shruthi]

Re-read the 2021 E/M documentation guidelines and note the words "when performed". The extent of the history and exam are determined by the treating provider.

Agree with the point. As per guidelines - The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.”
Again if its not documented, should they specify the reason? Just wanted to know to update our provider. Because in telehealth cases it will clearly be documented the reason for not performing PE.

 

[Orthocoderpgu]

Since the provider gets to choose how much or little history and examination is done there doesn't need to be a reason.

 

[amyjph]

Agree with above. However, if every single visit has no exam that's questionable depending on the specialty and nature of the services rendered. Are they doing a physical exam of some sort and just not "writing it down"/documenting it? This becomes more of a med/legal issue. Just because something may or may not be required for a certain code/code level doesn't mean the provider should stop documenting properly. I once had a provider that wanted to stop documenting certain things in an operative note only because when billing it was considered bundled and they knew they were not going to be paid for it. That's a really bad idea in my opinion. The provider must still document properly.

FAQs: Evaluation And Management Services (Part B)

www.novitas-solutions.com

8. Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines?
The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines.
While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.
The revised code descriptors state a "medically appropriate history and/or examination" is required.

https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/em_changes_FAQ.html#:~:text=Since%20history%20and%20physical%20exam,Yes.

Since history and physical exam are no longer required to level the visit, should I still document these elements?
Yes. Although history and physical exam are no longer required to level the visit, they are still important components in establishing medical necessity, supporting medical decision making, and providing high-quality care. Documenting these components helps maintain continuity of care and assists other care team members.