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Required Physician EXAM for future billable events?

  1. Default Required Physician EXAM for future billable events?
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    Hello, I'd like some input from the E/M experts. Our coders were given a directive that if the Physician does not perform a Physical exam on the Initial consultation OR any other established face to face visit such as a 'weekly status check' during course of treatment, then any and all follow up EM services (incident to) or otherwise are not billable.

    We have physicians who may not perform an initial exam, therefore, not meeting 3 out of 3 required elements (HEM) and we don't bill for the EM. Then the patient returns for follow up to discuss treatment, review tests, start treatment, etc. and if the physician meets the 2 out of 3 requirements, with still NO exam, we were told, we cannot bill the established patient visit until the physicican performs an exam.

    I belive this is incorrect, and I'd like some feedback.


  2. #2

    Ok, so in order to bill an Initial/New Patient/Consultation, all three components MUST be required (History, Exam, MDM), otherwise you cannot bill an E/M. I have read some errata (local MAC), which allows Inpatient Subsequent billing of an Inpatient billing if History or Examination was missing, however I cannot confirm this for outpatient office E/M visits. Note if Vitals (3 out of 7) were collected (could count as 1 exam element), you might be able to bill a low Initial/New/Consultation visit. Time documentation (if done properly) could also be used as an overriding factor.

    As you have mentioned, Established/Subsequent visits only require 2 or the 3 E/M components, History and MDM could fit that bill nicely.

    Hope this helps guide you.
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  3. Default
    Thank you Pathos. I have a solid understanding of the requirements for the EM service to be billable. Let's try another example: Inital visit is not billabe, (physican did not meet 3 of 3 requirements) The follow up visit is an INCIDENT TO.......since we are not billing to the PA, this incident to visit is billable b/c the physician did not meet the 3 of 3 in the first visit?

    Second case: INITIAL Outpatient shared visit
    The PA/ARNP/ are credentialed, the Intial visits are written in such a way that the PA's signature is underneath the work they performed (history & Exam). The physician's signature is under the MDM (sometimes w/Dr. exam, sometimes not) * Per CMS: If the "incident to' requirements are met, the physician reports the service. If the "Incident to"requirements are not met, the service must be reported using the NPP.
    IF the Incident to requirement IS met do we screen the E/M (using FIRST COAST, FL EM screening tool) as one whole document, even though the signatures represent the different work they performed?

    Thanks so much.

    And Yes, per CMS rules, if a hospital visit does not have a detailed and/or comprehensive History AND Exam, then the hospital consultation becomes subsequent. Initial Inpaitent consults does require that the History and Exam be detailed and/or comprehensive. (Pg. 57 Medicare Claims Processing Manual)

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