e/m visit

an established visit has an acceptable history, no exams, and an acceptable MDM and provider bills 99213. is it OK that there is no exam as 2 of 3 is only amount required for an established patient? or do all 3 elements need to be present and you are allowed to take the best 2 of 3?

does anyone have CPT® or CMS documentation backing up your answer?

Thank you, Michael

re: e/m visit

I would refer you to:

https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice/center/business_of_practice/cpt/EM_Coding_SUmmary_Guide_v2.pdf

re: e/m visit

http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html?redirect=/home/regsguidance.asp


here is the website from CMS for supporting documentation guidelines.

if the provider is only documenting the history and mdm, was the mdm risk of complications and/or morbidity/mortality of low to moderate severity.? and did he provide any kind of counseling time and was the history an expanded problem focused history. This is the only way he would meet the criteria of billing that level of service for the two out of three components.