Wiki DOCUMENTING IN NOTES

[HEATHER@MEDEVOLVECONSULTING.COM]

I AM GOING BACK AND FORTH W/THE PROVIDER IN AN OFFICE I AM CONSULTING IN. THEY ARE INSISTING THAT THEY NO LONGER NEED TO DOCUMENT ROS AND EXAM IN THE CHART NOTE AND IT QUALIFIES FOR LEVEL 3 AND 4 E/M. I HAVE NO KNOWLEDGE OF THIS BEING REMOVED FROM REQUIREMENTS. CAN ANYONE ASSIST?

 

[ckeeney]

What the guidelines state:
History and/or Examination
▶E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes.◀

This is in the CPT book. It is a bit optional but I would question that it is never needed. When the new guidelines came out in 2021 the language used was a medically appropriate history and exam as determined by the qualified healthcare professional.

 

[ambernic]

Per the AMA, "Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (eg, by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of office or other outpatient services." I took this to mean it should still be reported and documented when medically necessary. It just will not count toward selecting an E/M level. See attached resource