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? re: exams for established patient's

  1. #1
    Smile ? re: exams for established patient's
    Medical Coding Books
    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!!

  2. #2
    Location
    Columbia, MO
    Posts
    12,913
    Default
    Exam must be documented by the physician always regardless of specialty. It cannot be referred to from a previous visit or implied.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Smile Thank you
    Thank you Debra that is exactly what I thought but I just wanted to make sure that I wasn't missing something.

  4. #4
    Location
    Grand Rapids, MI
    Posts
    78
    Default
    Remember for Established Patients you only need 2 of 3 elements for E/M. So interval history and mdm would work.

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