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Count Previous Exam

  1. #1
    Default Count Previous Exam
    Medical Coding Books
    I have a provider who noted "Please refer to my previous exam for full physical examination." This previous exam was performed 1 month prior to the current visit. Does that seem appropriate to count those elements? It doesn't seem like it would be to me. It basically changes the level of the exam from 99214 to 99212.

    I think the exam should be completed each time, but maybe the ROS adn PFSH, even maybe HPI could be completed at a previous visit.

    Any thoughts/advice would be appreciated.

    Cory Bauer
    Rochester, MN

  2. #2
    The exam should be from the DOS. Only the ROS and PFSH can be referred to from another date, as long as the date is indicated in the chart and the provider appropriately documents any (if) changes.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  3. #3
    Ellenville, New York
    Default Agree with Melissa
    How could the provider know if there were any changes from the last exam without performing a current one? The patient can't give that kind of information to the physician as the patient doesn't do an exam on herself! This type of documentation is certainly a red flag, as this doesn't show if an exam was done today.


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

    2016 Secretary
    Ellenville, NY Local Chapter

  4. #4
    Thank you both. You confirmed the exact thoughts that I was having and will address it appropriately with the provider.

    Thanks again.
    Cory Bauer
    Rochester, MN

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