Wiki Time factor and exam element in E/M

[himanib]

The patient was seen with comprehensive Hx, a description of assessment and plan was described in detail. The provider says he spent 75% of the total time in C/CC. Time factor can be a key to coding in this scenario.

Now, the question is the provider has not entered any exam elements at all. According to him, considering the time factor, exam does not need to be there to code. I think the exam has to be there to come up with the assessment and plan. Any feedback? I looked up on CMS website, but could not find anything specific for this scenario.

 

[LLovett]

I agree with the provider in theory

If you are using time to level you don't need any specific elements to be documented.

What you do need is medical necessity.

I can understand why you are questioning this. This kind of note doesn't feel right. This is when I would want to clarify with the provider, was an exam done and just not documented or was it not necessary for this provider to repeat an earlier documented exam done. If the provider did an exam, whether they need it for leveling or not, it must be documented. If they are using another documented exam they should reference that document.

There is more to documentation than just supporting the level of service they plan to submit for payment. They need to make sure the document is a complete and accurate representation of the visit. This is for both patient care and medical-legal reasons.

Hope this helps,

Laura, CPC, CPMA, CEMC

 

[MnTwins29]

Just like I tell others when they say there is "no exam" - did the physician document ANYTHING that could be considered under the constitutional element of an exam, such as the patient's general appearance or vitals? If the concern here is that even though time based coding would be correct but there was no exam of the patient - I say to check for these elements. That way, at least there would be a PF exam (if using the three key elements). In my many years of doing this, I can count on one hand the number of times that I have not seen at least a consitutional exam element, even when the patient "refuses to be examined."