# E/M documentation without Physical Exam



## kmorga (May 6, 2015)

I have a provider who says the Physical Exam is not required to be documented to in order to bill a an existing patient E/M.  I am not a CPC so I am looking for some input on this.:confused


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## teresabug (May 6, 2015)

the E/M 1995 and 1997 documentation guidelines require at least 1 element in the area of the physical exam. So if the clinical staff charts 3 constitutional measurements, i.e. BP, temp and height, this will give your Dr. a problem focused exam. The pt's history and the medical decision making also play into the final leveling of the E/M code.


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## LLovett (May 6, 2015)

*I'm going to disagree*

There is no requirement that I am aware of in the guidelines that you have to do an exam.

In fact, if you are billing based on time, there is no requirement for any of the key components. 

Some payers may require things above and beyond official guidelines but I would really appreciate provision of supporting documentation stating exams are required per both 1995 and 1997 guidelines.

If you are dealing with a code that requires all 3 of the key components and time is not the controlling factor, then yes the provider must perform an exam or they cannot bill from that code set. 

Laura, CPC, CPMA, CPC-I, CANPC, CEMC


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## teresabug (May 6, 2015)

coding based on time is for COUNSELING of the patient and/or family/caregivers. If this does not occur you cannot code based on time.


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## amexnikki23 (May 6, 2015)

*2 out of 3 aint bad, right?*

So, just to clarify, if est pt, if the provider performs any 2 out of the 3 key components and meets the criteria, then it does not matter if its  History and MDM, or Exam and MDM, or History and Exam. But for new pts, they must meet the criteria to for all 3 key components. Is this correct?


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## teresabug (May 6, 2015)

for a new pt all 3 elements of the PFSH must be charted. For est pt's only 1 of the 3 is required. And yes in answer to your ? for all new pt's 99201-99205 the HX, exam and MDM elements have to be charted and met.


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## LLovett (May 6, 2015)

Per CPT guidelines, no it does not matter which 2 of the 3 key components you utilize to support your level in a 2 of 3 code. Some carriers may require one of them to be MDM though. 

You need to be careful though because medical necessity is the overarching criterion for level selection. You could have comprehensive history and exam on everyone, that doesn't mean a 99215 is medically necessary.

For new patients and other 3 of 3 codes, all 3 of the key components must meet or exceed the level in order to support it.

Laura, CPC, CPMA, CPC-I, CEMC


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## TTcpc (May 6, 2015)

LLovett said:


> Per CPT guidelines, no it does not matter which 2 of the 3 key components you utilize to support your level in a 2 of 3 code. Some carriers may require one of them to be MDM though.
> 
> You need to be careful though because medical necessity is the overarching criterion for level selection. You could have comprehensive history and exam on everyone, that doesn't mean a 99215 is medically necessary.
> 
> ...



I have to agree with Laura.  For an established patient you only need 2 out of the 3 components to code from.  We have chosen as a group to use the MDM as one and it is up to the discretion of the provider as to whether they use the history or exam as the second element.  Also, to clarify that time based billing is based on time spent during the visit in counseling *and coordination of care as long as it consitutes greater than 50% of the visit*.  
Per CMS transmittal :  The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care


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## bedforak1 (May 11, 2016)

I agree with Laura as well.


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