Wiki E&M documentation question

[adnil1121]

If no exam was done on an established can you still get to a level 3

 

[hewitt]

Sure, as long as the documentation support use of the code as follows: "Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family."

 

[NANJFLO]

You cannot eliminate the exam completely. All three components must be present;history,exam and MDM but only two of the three must meet or exceed the level.

 

[dianat68]

Actually, you can eliminate the exam completely on an established patient, and the resulting level will depend on the documentation in the history and MDM portions of the chart.