Wiki EM 2021 - Medically appropriate Examination

[sivakumar.s]

Hi All, Happy Friday!

Can we consider three vitals as a medically appropriate examination per 2021 EM OP (99202 -99215) coding guidelines?, Since we have considered three vitals as constitutional in other EM specialties. Please advise

 

[csperoni]

AMA specifies in https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
History and/or Examination
Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (eg, by electronic health record[EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of office or other outpatient codes.

To me, this means I do not even need to look at the exam or history to code 99202-99215. It even specifies "when performed." It is completely at the clinician's discretion what needs to be examined or not examined. So even no vitals could be a medically appropriate examination.

 

[sivakumar.s]

AMA specifies in https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
History and/or Examination
Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (eg, by electronic health record[EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of office or other outpatient codes.

To me, this means I do not even need to look at the exam or history to code 99202-99215. It even specifies "when performed." It is completely at the clinician's discretion what needs to be examined or not examined. So even no vitals could be a medically appropriate examination.

Thankyou for your clarification. As one of our provider documented only vitals under the examination no other systems are examined. In this case can we code ( considering vitals as medically appropriate exam) and complete the report OR we need to query the provider for medically appropriate exam? please advise.

 

[csperoni]

I would see no reason to query the provider as an exam is not even required at all. Not even the vitals are needed. I would not question the provider's judgement or documentation unless there is a valid reason to.

 

[sivakumar.s]

I would see no reason to query the provider as an exam is not even required at all. Not even the vitals are needed. I would not question the provider's judgement or documentation unless there is a valid reason to.

Thank you ☺