Wiki Is exam required?

[solocoder]

I understand that a "medically necessary" exam still needs to be documented for 2021, but I haven't found anything official that says an exam is strictly required. Has anyone else? What if the provider does not document ANY exam? Possibly they didn't think an exam was "medically necessary" at this visit??

 

[thomas7331]

By my reading of the guidelines, it is up to the provider to decide whether or not to perform an exam, and if so, what exam is or is not medically necessary. The wording (copied below) states that the exam is included in the E/M service when performed, but does not say that it must be performed. It is not a factor in coding and I have not seen any official guidance explicitly stating that an exam is required in order to report these codes. In my opinion, if a provider does not feel that an exam is 'medically appropriate' or necessary, that is their professional judgment call and it is not within the coder's scope to challenge it.

"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 extent of history and physical examination is not an element in selection of the level of office or other outpatient codes."

 

[trarut]

What is the context of the visit? Not all visits require an exam - sometimes the patient is just coming for a detailed discussion of results. As long as the content of the discussion is adequately documented and the time the provider spent is also documented, I wouldn't worry about the lack of exam and would code it on time.

 

[solocoder]

What is the context of the visit? Not all visits require an exam - sometimes the patient is just coming for a detailed discussion of results. As long as the content of the discussion is adequately documented and the time the provider spent is also documented, I wouldn't worry about the lack of exam and would code it on time.

By my reading of the guidelines, it is up to the provider to decide whether or not to perform an exam, and if so, what exam is or is not medically necessary. The wording (copied below) states that the exam is included in the E/M service when performed, but does not say that it must be performed. It is not a factor in coding and I have not seen any official guidance explicitly stating that an exam is required in order to report these codes. In my opinion, if a provider does not feel that an exam is 'medically appropriate' or necessary, that is their professional judgment call and it is not within the coder's scope to challenge it.

"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 extent of history and physical examination is not an element in selection of the level of office or other outpatient codes."

Thank you.