I could really use some feedback on this...
I have been told conflicting things and am so confused.
While you only need 2 of the 3 key components to choose a level. Doesn't one of those key components need to be the EXAM????
CMS states, that documentation of each patient encounter should include:
Reason for encounter and relevant history, physical EXAMINATION findings, and prior diagnostic test results.
If the exam wasn't necessary to come to a level of E&M then it would have an area of NONE next to the option when auditing, like it does for the ROS and PFSH.
Am I thinking WAY too much into this?
I have been told conflicting things and am so confused.
While you only need 2 of the 3 key components to choose a level. Doesn't one of those key components need to be the EXAM????
CMS states, that documentation of each patient encounter should include:
Reason for encounter and relevant history, physical EXAMINATION findings, and prior diagnostic test results.
If the exam wasn't necessary to come to a level of E&M then it would have an area of NONE next to the option when auditing, like it does for the ROS and PFSH.
Am I thinking WAY too much into this?