Wiki E&M audit

[dstein]

Are all three key components required to be documented when auditing an estabished patient? My provider is not documenting the EXAM, and her argument is that, "No signs of pregnancy induced HTN or no signs of pre-term labor" ARE her exam.

So when I audit her, she has no ROS and no exam. I want to scream!
Should I come down on her or am I over thinking things? When I audit her charts she is meeting the level because of her medical decision making is high.

Thanks for your help,

 

[penguins11]

for established patients you have to meet 2 out of the 3, what 2 those are does not matter, History, exam and or medical decision making. If the dr has absolutely no ros and you are using the history to determine the code, the most you could bill is a 99212, providing the medical decision making meets as well.