Wiki Establised patient??

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ortho1991

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If you have establised patient and you only need to meet 2 of the 3 key components must you doc phyical exam or can you bill with, just documented history and medical dicision making?

Any advice or guidance on this is very much appreciated

Thank you
 
cathy56 said:
If you have establised patient and you only need to meet 2 of the 3 key components must you doc phyical exam or can you bill with, just documented history and medical dicision making?

Any advice or guidance on this is very much appreciated

Thank you
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There are no specific DG's that say the exam portion must be one of the three. I however feel it is good practice to document something...... There were no vitals taken?
 
I say the same thing - there was absolutely nothing for an exam? No vitals? No statement that patient appers fine or NAD (no apparent distress), well developed, well nourished, etc. NOTHING at all like that? If you have just one of those statements, you at least have a consititutional exam element and therefore have a PF exam. I have seen this many times. "NAD. Patient refuses exam at this time." Well, I got the PF thanks to those three little letters of NAD.
 
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