Wiki No exam performed

[ADV]

I'm auditing E&Ms where NO EXAM is performed. These are established patients. There is no exam documented nor is there any note pointing to a nurse's exam or any other document. Is there any guideline line other than:

"For the following categories/subcategories, two of the three key components (ie, history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services: office, established patient; subsequent hospital care; subsequent nursing facility care; domiciliary care, established patient; and home, established patient."

That states it is acceptable (or unacceptable) not to perform an exam? I've had a physician state you should expect at least vital signs or some type of constitutional statement to be performed. I've heard coders state that if it says 2 out of 3 than not all three need to be performed but at least MDM should be performed.

Can someone point me in the right direction, please?

Thank you!!!

 

[smontague]

I was always under the impression that there should always be at least a Constitutional with vital signs documented, but that is how I was taught...is there a reason why your physicians are seeing patients and not documenting vitals or performing an exam?

Just thinking that maybe you should be looking for a different code/charge rather than an E/M if they aren't performing an exam.

 

[ADV]

Thanks for the reply. I'm doing an audit for fraud. I think the reason why the physician isn't documenting an exam is because he isn't actually doing one. I would like to back up the audit with as many guidelines and regulations as I can.

 

[mitchellde]

for an established patient the provider does not have to do an exam. But there should be a good reason noted to make it logical as to why not. Even if the nurse performed the vitals it does not count unless the provider makes a reference to vitals. But consider the patient that goes to the doctor to just talk about how they are feeling, mentally or physically. So there should be at least a note saying why no exam and what was talked about. Or perhaps the patient is a regular with a chronic illness and simple requested that no hands on be performed due to not feeling well because of the chronic problem, we would get this alot with our cancer patients. But again there should be something in the nte that explains this.
Perhaps you could provide an example of a note with the visit level billed for consideration.