According to documentation guidelines for an established patient it requires 2 of the 3 components. My question is do all three have to be documented and you use 2 of the 3. I have experienced doctors not who are not doing an exam and telling me to use the 2 that I have. I would appreciate some feedback.
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Wiki No exam
- Thread starter HOWRU2DAY
- Start date
MnTwins29
True Blue
I have used that before, especially if the presenting problem is well-established and this is a follow-up. However, I rarely have to use it, as there is usually some type of documentation that can be considered constitutional. Is there ANY documentation of the MD reviewing the vital signs taken by the nurse, the patient's general appearance, etc.?
drashby
Networker
Just to add my 2 cents - WPS (My Medicare Carrier) requires an exam. You can base your level on 2 of 3 but an exam must be documented. So check with your carrier/payor regarding their requirements. And as all ready mentioned, usually vitals are taken and count towards constitiutional in the exam.
MikeEnos
Guest
Another point to consider: If your provider is documenting an encounter without an exam documented, it stands to reason that the majority of the time spent may have been spent counseling the patient or coordinating care. In that case, you can select the level of service based on the time spent, but the provider must document A) the total length of the encounter B) that greater than half of the time was spent face to face with the patient and/or caregivers counseling them or coordinating care, and C) the content of that discussion. It's actually a really easy way to document, and it makes auditing a breeze!
Candice_Fenildo
Guest
Well said Mike