Results 1 to 3 of 3

99201 - Required exam

  1. Default 99201 - Required exam
    Medical Coding Books
    All 3 componants of a 99201, a problem focused history, a problem focused exam and straightforward decision making, must be met in order to code a 99201. If a new patient presents due to late menses what exam is required. Does this mean that a pelvic exam must be done? I'm getting mixed information as to whether it there only needs to be 1 organ or body system examined or if it has to be te affected system or body area.

  2. #2
    Ellenville, New York
    Default In "real" time...
    I have not seen an exam that did not included the affected area, as long as the patient mentioned a specific problem. In the strictest sense, the guidelines don't seem to help and I don't see why one other area may not be included (especially if constitutional, such as the only documentation being vitals and general appearance), but I have not seen this in my many years of E/M reviews.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

  3. #3
    Concord, NC or Rochester, NY
    It would be unusual to have a CC and then a diagnosis for a problem but no exam of the affected area. If I were an insurance carrier and audited the chart, medical necessity would be the major question. There is a defined problem but no exam so why are you seeing the patient?

Similar Threads

  1. Is an Exam required?
    By dstein in forum E/M
    Replies: 8
    Last Post: 09-20-2015, 04:38 PM
  2. Replies: 4
    Last Post: 08-25-2013, 10:03 AM
  3. exam required?
    By Bellaboo in forum Auditing General Discussion
    Replies: 3
    Last Post: 02-14-2011, 01:36 PM
  4. Exam required? OV requirements
    By kasdmb in forum Urology
    Replies: 1
    Last Post: 06-28-2010, 02:41 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.