Wiki Does an est. E&M need exam?

[meenda]

I always thought that to bill a visit, it needed to have an exam documented. But I am being told by a new company I work for that I only need EPF history and low MDM to bill a 99213. I have always asked my providers to document ANYTHING in an exam . I feel that to bill a visit, it should have something in the exam section...unless time is documented for counseling. Can someone tell me if I can send claims without an exam for ESTABLISHED Patients????

 

[thomas7331]

This has been discussed in the forum a number of times in the past so if you do a search you should be able to find a lot of previous posts. There are differing opinions about this. Personally, I do not feel that anything in CPT or CMS guidelines specifically requires an exam for an established patient if your level is supported by the History and MDM, and some professional auditors I've worked with have agreed with me. But as you'll see, other auditors have differing points of view and ultimately this would be an internal decision your practice would need to make. Certainly, the safest thing is to document at least one exam element, as you've advised your providers, as this would cover your bases for either situation in the even your notes were audited by a payer - it also helps to support in the documentation that a face-to-face encounter did take place.

 

[meenda]

thanks

Thank you for the info. I will check out the past posts.....but I will do as I am told, even if I think it isn't quite "right".

 

[Pam Warren]

Your company is confusing the elements of chart auditing (i.e. 2/3 key components on an established patient), with the need for medical necessity.

Per CMS, Medical necessity (not MDM) is the overarching criteria for code selection. So your providers' note must illustrate whatever was performed/provided to the patient was necessary from a medical standpoint, and must make a case to support what the provider wishes to bill. It must also report that the care provided to the patient was necessary, complete, medically sound, and appropriate.

Let's say the established patient presents with a bruised foot, after a fall. I cannot think of any reason why an examination would not be performed, in order to rule out a fracture, or to determine if there is some other sort of injury, to determine if films should be taken, if a referral is appropriate or to figure out if a cast/splint should be applied in the office. To submit a claim for a foot injury with only an HPI and Assessment/plan without the provider having documented his or her objective examination is negligent. Sure, you can code it based on the HPI and Assessment and plan, but there's a large amount of information missing here. What if that injured foot led to complications or infection? The fact that your provider never documented that he did an exam is going to be questioned during litigation, and he will be hard pressed to explain why, as a licensed physician, he did not look at the patient's injured foot. Most lawsuits are not because providers knowingly did the wrong thing. Most lawsuits are the result of laziness.

Purposely omitting parts of the E&M visit just to get the claims out the door quickly is a very good example of risky behavior.

 

[Pam Warren]

Thank you for the info. I will check out the past posts.....but I will do as I am told, even if I think it isn't quite "right".

If you go this route, and I strongly discourage it, make sure you document any discussion you have had with your managers about your thoughts that this is a risky approach to take. If you just go along with the flow, because you are being told to do so, even if you know they are telling you wrong, you are in violation of your code of ethics as a certified coder, particularly if you don't speak up.

"I just do as they tell me" is never an appropriate course of action for a trained, certified coder.

 

[thomas7331]

Hi Pam, thanks for your input, and I agree with what you're saying, but I think when medical necessity is brought into the picture, it becomes more about clinical documentation quality rather than coding. Certainly in cases such as the example you gave, a missing exam would reflect poor documentation quality, and something that should be brought to a provider's attention, but that's not a code selection issue. There are cases where a provider may not feel that an exam needs to be done or documented - for example, if the exam was completely normal at a previous visit, or if lab work was done or medications were adjusted requiring follow-up, in which case it may not actually be medically necessary to repeat an exam. The focus of such a visit may be just the patient's symptoms reported in the HPI, and the provider's MDM based on the lab and medication work. In these cases, I think it can be appropriate to assign an established patient code without documentation of an exam.

 

[Pam Warren]

I think the risk here is that the OP's company suggests that only HPI and MDM need be documented...ever, in order to support code assignment.

As coders, we should be careful to not fall into the trap of being only bullet-counters. Our roles as coders, and our understanding of quality documentation sets us apart from companies (or computers) that can assign codes based only on the elements of data that the documentation contains--whether it is pertinent, necessary or even present.

Although I recognize that in some instances (a behavioral health visit, for example) where a physical examination may not be necessary, we wouldn't want to ever set policies or procedures that eliminate documentation just because a code can be assigned without it.