# Exam Missing



## jessicaparker1 (May 2, 2011)

For a subsequent visit, only 2 of the 3 components are required. But does the physician have to perform an exam on his note?


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## btadlock1 (May 2, 2011)

Jessheartz said:


> For a subsequent visit, only 2 of the 3 components are required. But does the physician have to perform an exam on his note?



Yes - Per CMS Documentation guidelines (both sets):
http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
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;
-plan for care; and
-date and legible identity of the observer.

You can't document PE findings, if no exam was done. Hope that helps!


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## LLovett (May 2, 2011)

I have to disagree with your answer Brandi.

On established patients exam is not a required element. If they do the exam, yes they have to document it. But they only need to do the exam if it medically necessary. So there will be times when no exam is done or documented and that is perfectly acceptable.

Laura, CPC, CPMA, CEMC


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## btadlock1 (May 2, 2011)

LLovett said:


> I have to disagree with your answer Brandi.
> 
> On established patients exam is not a required element. If they do the exam, yes they have to document it. But they only need to do the exam if it medically necessary. So there will be times when no exam is done or documented and that is perfectly acceptable.
> 
> Laura, CPC, CPMA, CEMC



Well, to be honest, I've only determined that based on my interpretation of the rules I've read, and I could be wrong about it, but I understand it as: the 2/3 key components requirement for selecting the level of E/M for established patients doesn't necessarily mean that you only need 2/3, _period_ - it take it to mean that out of the 3 different levels achieved (Hx, Exam, MDM), you select the overall level based on the highest level reached by 2 of those 3 components. I haven't been able to find anything that clearly states that you only have to have 2 components documented, but if you can point me in the right direction to find such a publication, it would be much appreciated, because this is a topic I've pulled my hair out over, more than once! 

Here's the info I've pieced together to determine that you have to have an exam to bill an E/M:

As I mentioned earlier, CMS documentation guidelines state:
 
Each patient encounter should include:
– Reason for encounter and relevant history,* physical examination findings*, *and* prior diagnostic test results 
– Assessment, clinical impression, or diagnosis, 
– Plan for care
I consider the word "and" to be the active word in the sentence - they don't make a specific distinction for new/established. You can't have PE findings, without a PE.

Also, CPT guidelines aren't explicit in saying that you have to have 3 key components present, but it does imply it...
Under "Levels of E/M services" it says:
"The descriptors for the levels of E/M services recognize 7 components, 6 of which are used in defining the levels of E/M services. These components are:
History
Exam
MDM
Counseling
Coordination of Care
Nature of Presenting Problem
Time
The first 3 components (Hx, Exam, MDM) are considered key components in selecting E/M services.
The next 3 components (counseling, coordination of care, nature of presenting problem) are considered contributory factors in the majority of encounters. *Although the first two of these contributory factors (counseling, coordination of care) are important E/M services, it is not required that these services be provided at every patient encounter."*
The fact that it states that those 2 components are *not* required at every visit, implies that the others *are* required at every visit.  

It really seems like everything I've read, kind of beats around the bush on this subject; but like I said: if you have something that spells out, that just because only 2 components are required, means that only 2 components have to be documented, then *please* tell me where I can find it. Thanks!


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## btadlock1 (May 2, 2011)

*I was able to find this...*

Everybody seems to have a different opinion on the subject, so it's best to check with your MAC. If you have WPS Medicare, here's your answer:

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

*Q. Is it necessary to document all three components (History, Exam, and Medical Decision Making) for an established patient visit to bill an E/M 99211 - 99215 visit or must you bill 99499 if only two are documented. Keeping in mind, only two are required for established patients.*A . Our response to this question during recent a recent teleconference and multiple seminars was all three elements were required, but only two were used in choosing a procedure code. In response to questions from the physician community, we took this question to CMS. The 1995 and 1997 DG provide general principles of medical record documentation which states: "The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services." The information then goes on to state in part:
"The documentation of each patient encounter should include:
i. Reason for the encounter and relevant history, physician examination findings, and prior diagnostic test results 
ii. Assessment, clinical impressions, or diagnosis 
iii. Medical plan of care
iv. Date and legible identity of the observer. "


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## m.j.kummer (May 2, 2011)

Jessheartz said:


> For a subsequent visit, only 2 of the 3 components are required. But does the physician have to perform an exam on his note?



To much Jay Leno... wanting to have some fun... how would the physician perform the exam on his note?  So sorry...

Seriously now…

II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION
The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.
1. The medical record should be complete and legible.
2. 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;
• plan for care; and
• date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating and/or consulting physician.
5. Appropriate health risk factors should be identified.
6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

What does the punctuation mean?

The reason for the encounter must be documented
The relevant history must be documented
The physical examination findings must be documented
Prior diagnostic test results must be documented

OR – does it mean

The reason for the encounter must be documented
The relevant history must be documented
The relevant physical examination findings must be documented
Prior diagnostic test results must be documented

The punctuation demands the first case: The physical examination findings must be documented.

If there is no examination, the examination can not be documented.  

Almost always there is some form or examination.  The nurse may perform the physical portion of the constitutional exam (weight, blood pressure, respirations); the provider performs the appearance portion of the constitutional exam…

There are five levels of care for this type of encounter which all require documentation of TWO out of THREE key components.  Key components are those components that are medically necessary to determine the appropriate plan of care.

Only the provider can determine if a physical examination is medically necessary to determine the appropriate plan of care.


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## btadlock1 (May 2, 2011)

*Component requirements interpretation...longest post EVER!*



m.j.kummer said:


> To much Jay Leno... wanting to have some fun... how would the physician perform the exam on his note?  So sorry...
> 
> Seriously now…
> 
> ...



Agreed! Except that I would _stipulate_ that: the provider *does* have all the judgement in deciding whether or not a physical exam is medically necessary;* but if he doesn't document one, he can't bill 99212-99215*. 

The more I read these guidelines, they kind of make sense, and I can explain why they lead me to believe that all 'key' components have to be documented for those codes...(With color/other marks added for emphasis)
1."The descriptors for the levels of E/M services recognize 7 components, 6 of which are used in defining the levels of E/M services. These components are:
*History
Exam
MDM*
Counseling
Coordination of Care
Nature of Presenting Problem
Time
The first 3 components (*Hx, Exam, MDM*) are considered *key* components _in selecting _E/M services.
The next 3 components (counseling, coordination of care, nature of presenting problem) are considered contributory factors in the majority of encounters. Although the first two of these contributory factors (counseling, coordination of care) are important E/M services,* it is not required that these services be provided at every patient encounter*."

2. "For the following categories/subcategories, *two of the three key components* (ie, history, exam, MDM) _must meet or exceed the stated requirements to qualify for a *particular level *of E/M services_: office, established patient...etc."

3. "When counseling/coordination of care *dominates* (more than 50% of) the physician/patient and/or family encounter...then *time* shall be considered the key or controlling factor to qualify for a particular level of E/M services..."

#1 tells me that:
A. All of the 7 components, excluding time, are used in defining E/M levels.
B. Out of 6 remaining descriptive components, 4 (in red) are required at *every visit*. The other 2 (in Blue) are important and happen a lot, but not every visit needs them, so they aren't required. I think it's especially important to note that flexibility is only granted to those two components. (Time will obviously exist at every encounter, unless the physician is practicing out of a wormhole in space)
C. Out of the 4 *required* components, all except nature of the presenting problem are* also*_ eligible _to control the level of E/M service that is selected. 
#2 is very misleading in its wording; I think that the writers should be more aware of how confusing it appears. What I get out of it, when considering the differences between new and established, is that every code has stated requirements; for example, 99202 requires EPF Hx, EPF Exam, and SF MDM, and 99203 states that the code requires Detailed Hx, Detailed Exam, Low MDM. Similarly, 99213 has stated requirements of EPF Hx, EPF Exam, and Low MDM, but 99214 has Det. Hx, Det. Exam, Low MDM) From #1, we know that no matter what level of each component is done, they are still required at every visit, along with nature of presenting problem. But to qualify for the CPT code described in the book, the key components must be greater than or equal to 2/3 *stated* requirements for established codes, and all 3 must be greater than or equal to the stated requirements, to select a new patient code. The word 'Stated' is an important qualifier - it changes the meaning from 'Only 2 components are required' to bill a certain E/M, to 'Only 2 components have to be as extensive as is normally required' to bill a certain E/M. 
To put it another way, you can have a Det. Hx, Det. Exam, and SF MDM, but would still be considered a 99202 for a new patient, because not all 3 components were as great as the levels stated in 99203's description. But since established patients only require 2 or the key components to reach the level that coincides with the code description, to report a certain code. Since 2 of the 3 components in the example are Detailed, they both meet the description for 99214 - Detailed History, Det. Exam, and Moderate MDM. If medical necessity supports it, that's the highest level you can bill.



> Irrelevant Side Note:
> I have an odd way of remembering how to choose the highest possible level of new vs. established E/M's. I think that college grades are a good analogy to explain it.
> Imagine a writing class that, has 3 major assignments, and one written exam; all three assignments will be graded on their own merits, and taken into consideration for the final grade for the semester (the test, like nature of the presenting problem, doesn't count toward the final grade) - the final grade will be limited to the lowest grade achieved on any one assignment; and if any assignment is not completed, you will fail the class. That's how the key components contribute to an overall code assignment for a *new* patient code.
> Now, imagine that same writing class, except you have a much more relaxed teacher, who says that you'll be allowed to drop your lowest grade, and your final grade will be determined by the lowest of the 2 remaining scores; you'll still fail for an incomplete assignment.
> ...


#3 represents the only exception to the usual Key Components rules: the 'time' controlled visits. What I take from the requirement, is:
Remember #1 again - you still have 4 required components, but sometimes, you will also have one (or both) of the other 2 components, counseling and coordination of care. When those components are the most significant part of the visit (Say, as they might be, if a patient were coming in to discuss the results of a biopsy that showed cancer, and they needed reassurance and/or to establish a coordinated plan of care with specialists) they become the driving factor in level selection. But since 'counseling' and 'coordination of care' can't be quantified on their own, the amount of time spent on these efforts is used to assign a level for the component. The component(s) represented by time must make up *at least half of the visit*, and if they do, the amount of time documented (that can be substantiated by the documented counseling coordination of care efforts), becomes the key factor in code selection. I find significance in the fact that time as a component, is described using* singular *verbiage (*the* key or controlling *factor*) - I interpret that as time stands alone in code selection, _when_ it meets the requirements to have an impact. It's not an interchangeable stand-in, used to replace inadequate or missing components; it counts as all, or nothing.

I just wanted to explain my rationale for saying that established patients still require all of the same components, even if only 2 count in the level...sorry for the book!

P.S. Your punctuation question - the first reading you listed is correct. I could explain it, but it would take forever.


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## LLovett (May 3, 2011)

I still disagree with stating no exam no established visit.

WPS is my carrier and I actually have a practice that was audited (prior to my employment) and fined by the OIG on E/M. I am extremely comfortable in saying that this was not an issue when they looked at E/M services and the practice in question does not do exams on established patients due to the nature of the problems they treat and they are not billing based on time either.

Just my experience for what its worth,

Laura, CPC ,CPMA, CEMC


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## btadlock1 (May 3, 2011)

LLovett said:


> I still disagree with stating no exam no established visit.
> 
> WPS is my carrier and I actually have a practice that was audited (prior to my employment) and fined by the OIG on E/M. I am extremely comfortable in saying that this was not an issue when they looked at E/M services and the practice in question does not do exams on established patients due to the nature of the problems they treat and they are not billing based on time either.
> 
> ...



As I mentioned, it's a regional thing - our MAC (Trailblazer) has stated that it wouldn't be counted, and so as WPS Medicare, but other MAC's may not be as strict in their interpretation - there's a reason it was hard to find consistent information from the carriers on it - there's_ not _a consistent stance. This is one I don't mind disagreeing with you on, because I think it's one of situations where there's really not a 'right' answer - just what's right for where you live. That probably accounts for why Trailblazer's CERT errors were identified in over 90% of the claims reviewed, compared with other regions that had a much more reasonable error rate - they're scoring us harder, than even the OIG would. I appreciate the different perspective!


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## m.j.kummer (May 3, 2011)

btadlock1 said:


> As I mentioned, it's a regional thing - our MAC (Trailblazer) has stated that it wouldn't be counted, and so as WPS Medicare, but other MAC's may not be as strict in their interpretation - there's a reason it was hard to find consistent information from the carriers on it - there's_ not _a consistent stance. This is one I don't mind disagreeing with you on, because I think it's one of situations where there's really not a 'right' answer - just what's right for where you live. That probably accounts for why Trailblazer's CERT errors were identified in over 90% of the claims reviewed, compared with other regions that had a much more reasonable error rate - they're scoring us harder, than even the OIG would. I appreciate the different perspective!



I agree....  To *determine* the level only two of three are required …  if you have a problem focused exam and comprehensive history and moderate medical decision making, you have an exam but you do not have to consider that it was only a problem focused exam to determine that you can bill a 99214 based on medical decision making.  In the same way, if you have a comprehensive exam and history, but the medical decision making is problem focused (unless the history and exam were medically necessary to determine that the medical decision making was problem focused, which in the case of an established patient would be the exception rather than the rule) a 99215 could not be reported because the comprehensive history and exam are not medically necessary.  I love E&M’s.


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## btadlock1 (May 3, 2011)

m.j.kummer said:


> I agree....  To *determine* the level only two of three are required …  if you have a problem focused exam and comprehensive history and moderate medical decision making, you have an exam but you do not have to consider that it was only a problem focused exam to determine that you can bill a 99214 based on medical decision making.  In the same way, if you have a comprehensive exam and history, but the medical decision making is problem focused (unless the history and exam were medically necessary to determine that the medical decision making was problem focused, which in the case of an established patient would be the exception rather than the rule) a 99215 could not be reported because the comprehensive history and exam are not medically necessary.  I love E&M's.



You are exactly right; however I think that the controversy in this thread, is not about what level can be assigned when all 3 components don't match, but whether an E/M can be reported* at all *if any one of those components is not documented.


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## FTessaBartels (May 6, 2011)

*Well nourished patient NAD*

The above title constitutes an exam.  So would recording JUST BP or JUST weight. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Sanjit (Aug 13, 2016)

*At least Vitals would suffice that Exam has been performed*

There has been much arguments that Physical Exam must be documented in E/M report for established patient even if you conclude your level based good documentation of History and MDM.

But, let's take the real scenario:

a. I have witnessed almost thousands of Psychiatry E/M documentation without Physical Exam, and based on 2016 E/M guidelines, you can code 99212-99215 also for Psychiatry, and has been coded and approved by Audits.

b. There are many Internal Medicine E/M reports where I found History and MDM, along with only Vitals. So, it put a question my mind should we code with 2/3 concept even though we are ignoring Physial Exam component with vitals only.


I came through a comments of P Jensen of E/M university and I certainly agree with his comments:

_"Need a documented face-to-face encounter.  Even if the exam says, NAD that would be at least something.  I would ask the doc to go back and at least document the vital signs. That way you could bill for SOMETHING (level 1 new patient).  Or I guess you could conceivably bill as established office patient based on the MDM and history, but there must be evidence that a face-to-face encounter occurred.  PJ."_

I would also add to the thread that WPS Medicare has the following findings:
The choice of a procedure code for established or subsequent services is based on meeting or exceeding two of the three components: History, Exam, and Medical Decision Making. We would expect the provider to document some portion of all three elements. The 1995 and 1997 DG provides the general principles of medical record documentation which states: "The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services." The information then goes on to state in part:
Documentation should include
i.	Reason for the encounter and relevant history, physician examination findings, and prior diagnostic test results 
ii.	Assessment, clinical impressions, or diagnosis 
iii.	Medical plan of care
iv.	Date and legible identity of the observer. "


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## danskangel313 (Aug 14, 2016)

Putting the guidelines aside for a second, I don't understand why at least some kind of exam would be done, even if it's just "looking" at something. IMO, if no exam is done, the documentation should state that AND the reason why it was unnecessary. The only time I've ever not had an exam done personally is for a nurse visit to get a flu shot.


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