Wiki e/m help hpi and exam

[Tfailner]

Hi. I am a bit confused. my office was searching on the internet and found a paper from Family practice. that states for the different E/M levels est you need either the hpi, ros, pfsh OR the exam.. I know they only need two of the three (history, exam, or MDM) I thought the exam was a mandatory part of the chart... Please help.
thanks

 

[MnTwins29]

Not necessarily

There doesn't have to be an exam performed by the physician if he or she doesn't believe it is necessary. However, you STILL might have exam bullets on the progress note even if the doctor didn't do an exam. Best example I have seen - vitals taken by the nurse and reviewed by the physician. This can count as constitutional, even if the MD did nothing else.

 

[MikeEnos]

No, an exam is not a mandatory part of the chart. For example if the patient came in and most of the visit was spent counseling, you could select the level of code strictly based on time. Even without that, you could document a detailed history and demonstrate moderate medical decision making and that would justify a level 4 established patient office visit-- even without an exam.