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Thread: e&m when no exam documented and query

  1. #1

    Default e&m when no exam documented and query

    AAPC: Back to School
    We have a difference of opinion in my office and i need documentation to back this up. Am I correct that you cannot code any E&M level if the physician does not document that an exam was performed? He did not mark any organ systems or anything therefore you cannot code a level correct? my second thing Is it legal to query the physician about whether or not he did an exam and to document it?

    I have given the CPT book to my coworker about not being able to code a level when the exam is not documented however he says we should not be sending this back because its illegal. I was taught it is ok to query a physician???

  2. #2
    Join Date
    Apr 2007


    If this is an established patient you don't need an exam to code. If it is new I would go with the unlisted 99499.

    There is nothing wrong with asking the provider if they forgot to document something. It would be wrong to tell them they have to document something that did not happen.

    Laura, CPC, CPMA, CEMC

  3. #3
    Join Date
    Apr 2007
    York, Pa

    Default Also...

    Quote Originally Posted by katmryn78 View Post
    If this is an established patient you don't need an exam to code. If it is new I would go with the unlisted 99499.

    There is nothing wrong with asking the provider if they forgot to document something. It would be wrong to tell them they have to document something that did not happen.

    Laura, CPC, CPMA, CEMC
    The only thing I'd like to add to Laura's answer is that if it is a time based billing you could still code it as well, as long as all the time elements are documented.

    I code for an oncology practice and I will querry the docs if and when I see there was no exam documented, I try to give them the benefit of the doubt that they "possibly" have it hand written in the patient's chart but may have forgotten to dictate it but I don't prompt them. I'll say something like "I'm coding this visit and I will have to assign 992__ and scan a copy of the note for them to view, most times after reviewing that dictated note they can tell why I've down coded it and will sometimes say they did forgot to document or that they only did vitals or whatever the case may be. I don't say " hey you forgot the exam".
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #4


    For Laura's response if an exam is missing for an established patient it is okay because only 2 out of the 3 elements are required ?but I thought that an exam must be one of the elements? If anyone has any information that an exam is not required can they let me know. thanks

  5. #5
    Join Date
    Apr 2007
    North Carolina


    Q4. Can you please clarify for an established patient visit do all three components have to have been performed and then only two of the three components used for choosing the procedure code or do only two of the three components have to be documented?

    A4. Our response to this question during a recent teleconference and multiple seminars was all three elements were required, but only two were used in choosing a procedure code. In response to questions from the physician community, we took this question to CMS. The 1995 and 1997 DGs provide general principles of medical record documentation, which states, “The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient’s status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.” The information then goes on to state in part, “The documentation of each patient encounter should include:

    •Reason for the encounter and relevant history, physician examination findings, and prior diagnostic test results
    •Assessment, clinical impressions, or diagnosis
    •Medical plan of care
    •Date and legible identity of the observer“


    We have providers that, at times, have limited exams due to the nature of their specialty (Vitals, appearance, psych) and code based on time (counseling and coordination of care). Depending on the presenting problem, it is possible to have a limited or no exam but the documentation should be bullet proof in the event of an audit.

  6. #6


    Thank You Rebecca! I have explained to our physicians that all 3 must be documented HPI, Exam, & MDM to obtain a level. If it is based on time it must be documented correctly and an exam may not have been perfomed.

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