# Complete Exam????



## LewinFamily (Oct 12, 2010)

I am performing an audit and on the E&M there is no indication that an examination was done. It states no vitals or urinalysis.. So the doctor did not perform an exam. Would this still be a billable visit? Or would the examination be problem focused?

Also, if you know of supporting documentation showing that an exam needs to be performed that would be helpful!

Thank you!


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## MikeEnos (Oct 12, 2010)

What type of E/M service is it?  Not all E/M services require an exam.  Office or other Outpatient services (99211-99215) only require 2 of 3 key components (History, Exam, MDM)

Also, was a physical attempted but refused by the patient?  If that was documented, the physician can still get credit for that.  

Also remember that when counseling and/or coordination of care dominates (more than
50%) the physician/patient and/or family encounter (face-to-face time
in the office or other outpatient setting or floor/unit time in the hospital
or nursing facility), then time may be considered the key or controlling
factor to qualify for a particular level of E/M services. This includes time
spent with parties who have assumed responsibility for the care of the
patient or decision making whether or not they are family members (eg,
foster parents, person acting in loco parentis, legal guardian). The
extent of counseling and/or coordination of care must be documented
in the medical record.

I hope this helps.  The information cames mostly from the Evaluation and Management Notes section, except for the tidbit about a patient who refuses part (or all) of the exam.  I'll try to find that link if you are interested.


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## LewinFamily (Oct 12, 2010)

This is a consult.. new patient.. medicare.. so I would need 3 components.. and the MD did not attempt the exam at all.. Just stated no vitals were done and then went on to the plan/ treatment. 

I was looking for a time indication and code off that.. but he didn't state any.. and the coder who did this originally coded it as a 99244????? and bill it out...


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## jdibble (Oct 13, 2010)

If he did not do an exam for an initial visit and did not document time and content to try for consultation time, this cannot be billed out with the code that the was billed, or any of the initial E/M levels.  

The doctor must do a physical.  I had a situation where the patient was unwilling to give a history and refused an exam.  I asked a rep from Highmark Medicare Services if this was a billable visit, and she advised that if the History is documented that the doctor attempted to get the History from the patient or another source and why it was unobtainalbe you could claim a comprehensive history, however the exam had to be done regardless of the patient's mental status.  Without the Exam you cannot bill with any of the E/M levels.  She suggested to bill with the unlisted code 99499 and you will have to send the note for review.

Hope this helps.


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## RebeccaWoodward* (Oct 13, 2010)

I agree with 99499.

*In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). *The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose.

http://www.cms.gov/manuals/downloads/clm104c12.pdf

Page 38


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## LewinFamily (Oct 15, 2010)

Okay thanks.. that is what I thought.. but wanted to be sure!


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## plasticscoder (Apr 19, 2018)

Hi Mike... I'd be interested in that link re patient refusal. Thank you



MikeEnos said:


> What type of E/M service is it?  Not all E/M services require an exam.  Office or other Outpatient services (99211-99215) only require 2 of 3 key components (History, Exam, MDM)
> 
> Also, was a physical attempted but refused by the patient?  If that was documented, the physician can still get credit for that.
> 
> ...


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