Urology Coding Alert

Question: Recently, when coding for an E/M encounter for a follow-up patient, I noticed that our physician documented the patient’s history and recorded vitals, but didn’t perform a physical examination. He had also written a detailed treatment plan for the patient. Can I report an E/M code for this encounter, even though our clinician did not perform a physical examination?

South Carolina Subscriber

Answer: If you look at the E/M code descriptors for “new” and “established” patients, you will notice that established patient E/M codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...) need only two of the three components of history, examination and medical decision-making. New patient codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components ...), by contrast, need all three elements to be performed by your clinician before you can report them.

Since your clinician has recorded history and documented the treatment plan (medical decision-making) and the patient is an established patient, you won’t need your clinician to perform a physical examination for you to report an E/M code for the visit.

That said, both the 1995 and 1997 versions of the documentation guidelines for E/M services maintained by the Centers for Medicare and Medicaid Services (CMS) consider recording vital signs to be part of the physical examination.