What type of E/M service is it? Not all E/M services require an exam. Office or other Outpatient services (99211-99215) only require 2 of 3 key components (History, Exam, MDM)
Also, was a physical attempted but refused by the patient? If that was documented, the physician can still get credit for that.
Also remember that when counseling and/or coordination of care dominates (more than
50%) the physician/patient and/or family encounter (face-to-face time
in the office or other outpatient setting or floor/unit time in the hospital
or nursing facility), then time may be considered the key or controlling
factor to qualify for a particular level of E/M services. This includes time
spent with parties who have assumed responsibility for the care of the
patient or decision making whether or not they are family members (eg,
foster parents, person acting in loco parentis, legal guardian). The
extent of counseling and/or coordination of care must be documented
in the medical record.
I hope this helps. The information cames mostly from the Evaluation and Management Notes section, except for the tidbit about a patient who refuses part (or all) of the exam. I'll try to find that link if you are interested.
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