Wiki documentation

[MAWK]

I have two providers that don't always include physical exam in their documentation. All they have in their documentaiton is the HPI and the Assessment plan. Would this be a 99212? Thanks.

 

[RFoster1]

It is my understanding exam elements can be pulled from other areas of the note if there is not a section dedicated to exam, but without seeing the actual dictation, I couldn't say what level it would support.

 

[alannae]

It would also depend on whether this is for an established or new patient. Established patient visits only require 2 of the 3 be used to determine the level. The level for an established patient can be determined based on the history and medical decision making (excluding the exam).

This is not to say that an exam is not a needed component. You should encourage them to document something, even if it's observational such as mood or appearance. If there is a nurse doing vitals, that counts towards the exam.

good luck!