cshelton1956@comcast.net
Networker
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What if an established patient comes back and no P.E. is documented at all. Can you still give it a level?
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Wiki No p.e. documented
- Thread starter cshelton1956@comcast.net
- Start date
Squiabro
Networker
If history is documented, and medical decision made and documented..then yes, a low level EM can be assigned.
Tonyj
True Blue
Why would it be a low level? I feel the level would be dependent upon the documentation of the HPI and MDM and the insurance carrier. The insurance carrier because you would need to know if they'd accept the claim w/o a P/E. Established pt's require 2 of 3 components. Which would mean you could technically have a level 5 with no P/E. And not to mention time based codes.
MnTwins29
True Blue
As I always state when a question like this comes when it is asked if "no exam" was done - are you sure that there was NOTHING that could at least constitute a constitutional element of an exam? Did the physician document the general appearance of the patient without specifically calling it an "exam"? Were vitals taken and reviewed by the physician? If you have anything like this documented, you could use this as the constitutional element and then you have one for a PF exam. And since you are using Hx and MDM to determine the level anyway with an established patient, it won't downgrade the code level, but does answer the problem of "no exam."