# exam required?



## Bellaboo (Feb 10, 2011)

NP documents detailed history,moderate medical decison making , but  no exam
No time noted  so cannot code on time. Is at least one exam bullet required or would
this be a 99214?  Thanks for any help


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## rthames052006 (Feb 10, 2011)

Bellaboo said:


> NP documents detailed history,moderate medical decison making , but  no exam
> No time noted  so cannot code on time. Is at least one exam bullet required or would
> this be a 99214?  Thanks for any help



For established visits you only need 2 of the 3 key components in order to qualify for a level of service.  Did the doc not record/take vitals.

Check your CPT book for the info regarding which visits require 2 or 3 key components.

Good luck


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## Bellaboo (Feb 10, 2011)

No vitals were documented either, thats what makes me question it can be coded at any level  . Yes 2 of 3 are required  but does that necessarily mean no exam at all
as even for a problem focused exam  at least 1 element is required
Thanks  appreciate  any help


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## FTessaBartels (Feb 14, 2011)

*2 out of 3*

If the documentation meets two out of three for an established patient visit, that's what you code.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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