# chart note with no physical exam



## sandrasperrazza (Feb 6, 2013)

When auditing charts, I have come across no physical exam, how can you perform the audit without that?


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## hmagao (Feb 6, 2013)

I would start with asking the physician if there was one done just not documented.


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## MikeEnos (Feb 8, 2013)

Of course, it could have also been a visit that was mainly spent counseling the patient.  In that case you could code it based on time if that were documented.

Even without time, only 2 of the 3 key components are needed for a follow up office patient or subsequent hospital care progress note.  So even if you just have a history and MDM, that's enough to select a level of service.


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## maddismom (Feb 8, 2013)

Check with your CMS carrier; we were told by Noridian that all three components must be performed regardless if the patient was established and they were quite serious about this.


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## vanrex (Nov 12, 2013)

Has Noridian published anything that can be referenced (printed) regarding a physical exam being required for every encounter?


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## MnTwins29 (Nov 12, 2013)

*Absolutely NO exam elements?*

Even though there might not have been an exam performed, were vitals taken and noted by the physician?  Did the doctor document the general appearance of the patient, such as no apparent distress, appears well, etc?   If you at least have this type of documentation, you do have the constitutional element for the exam and does count for a problem-focused exam.  Sure, it's not much but for a new patient or for those carriers like Noridian that would require all three for an established visit, you DO have a low-level exam.


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## TTcpc (Jan 8, 2014)

I agree with Lance.  If you can pull some kind of constitutional or even psych, was patient anxious, nervous. or depressed, I would use it.  I work with neuro and some of our patient's come in with seizures that are brought on by a psychiatric condition so there may not be a "physical exam" as most would see, but they do reference at least vitals taken when brought into the exam room and during the counseling time will reference the psychiatric state of the patient, so I would pull from that to count.


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