Wiki jwertane

[jwertane]

Can an E&M level be assigned for an IP hospital round if the MD does not examine the patient. Talks about labs, plan but since patient was asleep he did not examine. Also documents discussion with admitting MD for medication changes. Thanks in advance!

 

[MnTwins29]

Whenever I see a question like this, I always answer with a question: did the physician document ANYTHING about the patient's general appearance, how he is feeling or anything similar. Even without an "exam", you can get at least a problem focused level for the exam if there's documentation of the appearance as that would be a constitutional exam.