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Exam documentation-can this be used??

  1. Default Exam documentation-can this be used??
    Medical Coding Books
    I have a doctor that is stating under the exam portion of the note " Exam similar to that noted previously". Can this be used to support the level of E/M? I would love any suggestions!!!! Thank you!

  2. #2
    That statement on an office note would prompt me to think "previously when?" and "similar how?" It doesn't tell me what the provider actually did on the date of service billed and I wouldn't consider it adequate to support the level.

    Hope this helps!


  3. Default
    Thank you Karen! This is the way I feel as well but I just wanted some backup before I go to the doctor.

  4. #4
    Kingsport, TN
    The provider can use this type of verbage but he/she must give the specific date of service that he is referencing. Hope this helps.

  5. #5
    Milwaukee WI
    Default No exam documented
    As far as I am concerned "exam similar to that noted previously" is NO documentation of an exam at all. You'll have to code based on just history and MDM.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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