tci E/M Coding Alert - 2016 Issue 10

Reader Question: No Physical Exam? Established E/M Possible

Question: I have newly joined family medicine coding. Recently, when reporting an E/M encounter for a follow-up patient, I noticed that our family physician (FP) didn’t perform a physical examination for the patient. He did, however, document history and record the patient’s vitals. He had also written a detailed treatment plan for the patient. Can I report an E/M code for this encounter, even though our clinician did not perform a physical examination? Vermont Subscriber Answer: If you look at the descriptors for “new” patient E/M codes and “established” patient E/M codes, you will notice...

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