LauraLight
New
Hello! We are all aware that the extent of a physical exam is no longer considered in choosing an E/M level for coding. However, it is still my understanding that CMS expects that an exam be documented in order to have a complete note, and be reimbursed as a medically appropriate and necessary visit. We of course cannot decide how extensive an exam should be; That is left up to the provider to determine based on their own medical and professional judgement. However, it has always been my understanding since the expiration of the 95/97 guidelines that an exam still should be a component of the visit, just no longer used to determine code level.
Does anyone have any references from CMS/Palmetto GBA or AMA handy that they could share? I have researched this recently and found it is still needed, but strangely cannot find it while I am reviewing my research, now. Thank you, all!
Does anyone have any references from CMS/Palmetto GBA or AMA handy that they could share? I have researched this recently and found it is still needed, but strangely cannot find it while I am reviewing my research, now. Thank you, all!