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Thread: Exam Missing

  1. #11
    Join Date
    Apr 2007
    Lubbock, TX


    AAPC: Back to School
    Quote Originally Posted by m.j.kummer View Post
    I agree.... To determine the level only two of three are required … if you have a problem focused exam and comprehensive history and moderate medical decision making, you have an exam but you do not have to consider that it was only a problem focused exam to determine that you can bill a 99214 based on medical decision making. In the same way, if you have a comprehensive exam and history, but the medical decision making is problem focused (unless the history and exam were medically necessary to determine that the medical decision making was problem focused, which in the case of an established patient would be the exception rather than the rule) a 99215 could not be reported because the comprehensive history and exam are not medically necessary. I love E&M’s.
    You are exactly right; however I think that the controversy in this thread, is not about what level can be assigned when all 3 components don't match, but whether an E/M can be reported at all if any one of those components is not documented.

  2. #12
    Join Date
    Apr 2007
    Milwaukee WI

    Default Well nourished patient NAD

    The above title constitutes an exam. So would recording JUST BP or JUST weight.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #13

    Default At least Vitals would suffice that Exam has been performed

    There has been much arguments that Physical Exam must be documented in E/M report for established patient even if you conclude your level based good documentation of History and MDM.

    But, let's take the real scenario:

    a. I have witnessed almost thousands of Psychiatry E/M documentation without Physical Exam, and based on 2016 E/M guidelines, you can code 99212-99215 also for Psychiatry, and has been coded and approved by Audits.

    b. There are many Internal Medicine E/M reports where I found History and MDM, along with only Vitals. So, it put a question my mind should we code with 2/3 concept even though we are ignoring Physial Exam component with vitals only.

    I came through a comments of P Jensen of E/M university and I certainly agree with his comments:

    "Need a documented face-to-face encounter. Even if the exam says, NAD that would be at least something. I would ask the doc to go back and at least document the vital signs. That way you could bill for SOMETHING (level 1 new patient). Or I guess you could conceivably bill as established office patient based on the MDM and history, but there must be evidence that a face-to-face encounter occurred. PJ."

    I would also add to the thread that WPS Medicare has the following findings:
    The choice of a procedure code for established or subsequent services is based on meeting or exceeding two of the three components: History, Exam, and Medical Decision Making. We would expect the provider to document some portion of all three elements. The 1995 and 1997 DG provides the 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:
    Documentation should include
    i. Reason for the encounter and relevant history, physician examination findings, and prior diagnostic test results
    ii. Assessment, clinical impressions, or diagnosis
    iii. Medical plan of care
    iv. Date and legible identity of the observer. "
    Last edited by Sanjit; 08-13-2016 at 03:56 AM.

  4. #14


    Putting the guidelines aside for a second, I don't understand why at least some kind of exam would be done, even if it's just "looking" at something. IMO, if no exam is done, the documentation should state that AND the reason why it was unnecessary. The only time I've ever not had an exam done personally is for a nurse visit to get a flu shot.

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