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Need opinions e&m with no exam

  1. #1
    Alexandria, LA
    Default Need opinions e&m with no exam
    Medical Coding Books
    I am perfoming an audit for a sleep medicine specialist. He routinely bills 99212 or 99213 for his follow up visits, however, he does not perform an exam on these patients. Granted, an established patient visit only requires 2/3 of the key components be met or exceeded, but I'm a little hesitant in giving the credit without ANY exam items.They only have 2 vitals, so I can't even give constitutional. There is no time documented, so I can't code based on time.
    I've seen articles that state that this is acceptable, and others that say all three components must be performed.

    I'd appreciate any opinions.

    Wanda S. Wages, CPC
    Precision Practice Services of Louisiana

  2. #2
    Milwaukee WI
    Default 2 out of 3
    If history and MDM meet the standard for the level billed you are fine.

    By the way ... three vitals is a requirement for 1997 guidelines. 1995 guidelines allows you to "check" constitutional if you have ANYTHING in that system - one vital sign - or just a notation "well-nourished male."

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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