For billing purposes:
For a new patient you need 3 of 3 areas so an exam is required unless the physician has documented time spent and greater than 50% is in counseling and/or coordination of care. For an established patient only 2 of 3 areas areas required, so an exam is not necessarily needed, they could have history and MDM.
Now, whether or not an exam is medically indicated is for the physician to determine.
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