Gastroenterology Coding Alert

Question: I am auditing some of my gastroenterologist's E/M visits, and discovered that he's not dictating a "physical exam" on the patient. He gives reason for the visit (i.e., vitals, past history, assessment and plan), but no physician exam notes on any follow-up patient. I'm pretty sure we need some type of documented physical exam (e.g., general mental status, general appearance, and orientation). When I discussed it with him, he says documented physical exam not necessary for patients who are returning for follow-up appointments. Can I bill E/M without the physical exam section filled in?

Alaska Subscriber

Answer:  Your gastroenterologist is correct. Follow-up visit of established patients requires only two out of three key components for a level of service qualification. In this case you would code each of the medically necessary office visits (99212-99215). However, it's different for new or consult patients who require all three components.