jwhite2637
Contributor
If there is no physical exam documented, can you still bill an E/M level for an outpatient visit using the HPI and MDM?
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Wiki Physical Exam missing...
- Thread starter jwhite2637
- Start date
That would depend on several factors:
1. Is this a new or established patient? If this is a new patient, the answer would be no, you could not bill out an e/m level UNLESS this visit was based on time.
2. Know your carrier guidelines. I know some carriers require which specific key components must be used, although my carriers ddo not.
Hope this helps.
mitchellde
True Blue
are you coding for the physician or for the facility?
jwhite2637
Contributor
I am actually auditing for the physician side. It is an outpatient visit.