Wiki Physical Exam missing...

If there is no physical exam documented, can you still bill an E/M level for an outpatient visit using the HPI and MDM?

That would depend on several factors:

1. Is this a new or established patient? If this is a new patient, the answer would be no, you could not bill out an e/m level UNLESS this visit was based on time.

2. Know your carrier guidelines. I know some carriers require which specific key components must be used, although my carriers ddo not.

Hope this helps.