# Is an Exam required?



## dstein (Sep 11, 2015)

I could really use some feedback on this...
I have been told conflicting things and am so confused.

While you only need 2 of the 3 key components to choose a level. Doesn't one of those key components need to be the EXAM????

CMS states, that documentation of each patient encounter should include:
Reason for encounter and relevant history, physical EXAMINATION findings, and prior diagnostic test results.  

If the exam wasn't necessary to come to a level of E&M then it would have an area of NONE next to the option when auditing, like it does for the ROS and PFSH.

Am I thinking WAY too much into this?


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## CodingKing (Sep 11, 2015)

As my coding coach states. You must have a HEM to have an E&M. Yes you need to do an exam. However, established only requires 2 of 3 means is you don't have to meet all 3 levels specified in the CPT book.

For instance

Established 99214 requires meeting 2 of 3 of the following

Detailed History
Detailed Examination
MDM of Moderate Complexity

If your exam is Problem focused, History Detailed & MDM Moderate you can still code the 99214 (level 4) even though Exam is not considered detailed you can throw it out of the equation

If this happened to be an new patient you would need to meet 3 of 3 so if the exam was Problem focused you couldn't code anything higher than 99201 (level 1)

When its 3 of 3 you code to the lowest. when its 2 of 3 you can throw out the lowest


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## thomas7331 (Sep 12, 2015)

I would have to disagree - I have never heard that an exam is required on an established patient visit.  The code descriptors for each established patient E&M codes states that it 'requires at least two of these three' components - it does not state that it requires all three but only two must meet the stated level. You can meet two of the three required components by documenting the appropriate levels of history and MDM alone.  Can anyone else weigh in on this?


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## CodingKing (Sep 12, 2015)

thomas7331 said:


> I would have to disagree - I have never heard that an exam is required on an established patient visit.  The code descriptors for each established patient E&M codes states that it 'requires at least two of these three' components - it does not state that it requires all three but only two must meet the stated level. You can meet two of the three required components by documenting the appropriate levels of history and MDM alone.  Can anyone else weigh in on this?



I wasn't sure if you were responding to me or the original post. I believe you still have to do an exam for it to qualify as an E&M but for established you can ignore how intensive the exam was in the scoring if the other 2 components rated higher. I'm not sure i'd ever want to see a Dr who just comes up diagnosis by what i tell them.


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## nnewton224 (Sep 15, 2015)

When it is an established patient only 2/3 is required so if they did not do an exam you would base the level off the history and MDM. An exam is not required and in my job we would not send the chart back to the client and ask for one in order to determine the level.


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## ndanh01 (Sep 17, 2015)

I would have to agree with thomas7331 on this, with that being said... CMS also states that medical necessity is the overarching criterion for E/M services. Without the exam, you might have trouble proving the medical necessity for that visit.


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## thomas7331 (Sep 20, 2015)

I think we're confusing issues here - whether an exam is clinically necessary, e.g. to make a diagnosis or support the medical necessity of a service, is different from whether or not it is necessary to have that in the documentation to code an established patient E&M visit.  

Required elements of codes are stated explicitly (for instance, a face-to-face encounter or a chief complaint are requirements of certain codes).  There is no such requirement stated that an exam must be document for an E&M established patient code.  Granted every practice should evaluate their risks and set their own guidelines what they think best protects them, but at the same time, providers are already heavily burdened with regulations without us coming up with new ones.  

It is perfectly reasonable that in certain circumstances, a provider might not feel the need to repeat an exam done at a previous encounter and that the history and MDM components alone constitute a medically necessary service of value that should be reimbursement.


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## thomas7331 (Sep 20, 2015)

...and OK, yes I do know correct English grammar, I just sometimes forget to proof my responses before hitting the send button, lol.


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## Peter Davidyock (Sep 20, 2015)

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings.
 While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services is appropriate: 
❖	The medical record should be complete and legible; 
❖	The documentation of each patient encounter should include: 
?	Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; 
?	Assessment, clinical impression, or diagnosis; 
?             Medical plan of care; and 
?	Date and legible identity of the observer


from the Medicare Evaluation and Management Services Guide

Granted not every situation is going to require an exam, a nurse visit is a good example. To meet an established level I would look for 2 of the 3 to meet or exceed the level requirements before I would assign a code. To take the 2 of 3 at face value to mean I only need to do 2 would mean that you could code an established visit with a history and an exam and no mdm.

I wouldn't do it.


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