Wiki E/M Exam question

[jennyaharvey]

I am auditing for a physician that doesn't perform an exam for each visit, but rather references an exam from a previous visit and notes that there are no changes.

Is he allowed to get credit for this prior exam in the same manner that we can give credit for a ROS that was previously obtained if the provider documents that it was reviewed and notes any changes? Please provide references for your answer.

Thanks!

 

[Pam Warren]

No, the exam has to be real time. The DG (both 95 and 97) indicate the BA/OS that "must be examined" in order to qualify for a particular level of exam. As an Objective element of the SOAP note, the provider cannot use another physician's subjective opinion to qualify for his/her exam.

Pulling over exam documentation from a previous encounter is just that kind of EHR documentation concern that's prevalent on the CMS's and the OIG's radar. Make sure they do the work.