Established Visit Exam Required

A established visit only states 2 of the 3 components are required. Does the physician have to perform an exam on the note?

Does anyone have any guidance from Cahaba Medicare on this?

Comments

  • Were vitals taken? 3 vitals + 1 exam element
    Did the physician document time?


    Mindy L Dowd CPC,CPMA
    Denver Arthritis Clinic
    200 Spruce St
    Suite 100
    Denver,CO 80230
    (303)302-7433
    mdowd@dacdenver.com

  • You do not need an exam for an established patient, it can be deferred. This is usually a rare circumstance and on occasion, the visit is based on time. Documentation should obviously justify the need for billing a visit. With that said, I do not know the requirements of that contractor.
    Jen Vasquez, CPC, CEMC
    Sent from my Verizon 4G LTE smartphone

  • yes 3 vitals were taken but there is no documentation of time in the note.
  • it is 2 of 3 - so any 2 of the three. This means that if your doctor documents the appropriate level of:

    history and exam, or
    history and medical decision making, or
    exam and medical decision making

    they are ok. No - an exam does not have to be on every note if you have the appropriate history and mdm documented. There are some that may say "one of the 2 must be the exam" or "one of the 2 must be the medical decision making", but that is not true with the 95 and 97 "guidelines" and if they say so - ask them to prove it with something official from CMS. They won't be able to. Now - they may find a magazine article or something from the AMA or some other private association or group - but it's not "official" and enforceable unless it comes from the CMS or OIG or government (in my opinion)

    I hope this helps.

    Don
    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    books & webinars at https://shop.donself.com

  • 3 vitals equal one exam element....but you can use History and MDM to establish the level of service-2 of 3


    Mindy L Dowd CPC,CPMA
    Denver Arthritis Clinic
    200 Spruce St
    Suite 100
    Denver,CO 80230
    (303)302-7433
    mdowd@dacdenver.com


  • edited May 2017
    Just to add to that you might want to check with the payer. I have come across at least one MAC that requires some exam even for an established pt. I remember this because I had a discussion with a presenter that was stating there must be exam and to my surprise she provided the information from the MAC. I do not at this moment remember which MAC it was.



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