Wiki ? re: exams for established patient's

[medicode3]

Hello Everyone,
I had a quick question. I am new to Urology coding but not to coding for other specialties. I have a question.....I have been told that for established visits the physician does not have to include a GU body area or organ system in the exam. I thought with ANY SPECIALTY you had to include the pertinent organ system in the exam especially when it is a specialty. Am I wrong about this? Can anyone help me out? Thanks!!

 

[mitchellde]

Exam must be documented by the physician always regardless of specialty. It cannot be referred to from a previous visit or implied.

 

[medicode3]

Thank you

Thank you Debra that is exactly what I thought but I just wanted to make sure that I wasn't missing something.

 

[wrightju1]

Remember for Established Patients you only need 2 of 3 elements for E/M. So interval history and mdm would work.