Forum - Questions & Answers

Aug 26th, 2010 - paulapreston 8 

Documentation for a 99243 visit

Can someone please tell me how to address the following:
As we all know, this code requires that 3 of 3 elements be met & properly documented. I have a very knowledgable, seasoned physician that stated
"Physical exam today revealed no appreciable findings" on a recent consult
note. Does anyone out there feel this is an acceptable documentation? How
do I convince him this would not stand up in an audit? Any help is appreciated.
Paula P

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Aug 26th, 2010 - jschmutz   323 

Exam documentation

From the documentation he provided, one can only ascertain that a problem focused exam was performed, so the highest level he could report is a level 1.

Ask him how he would differentiate between a level 1 exam and a level 5 exam based on his statement. We have no idea what the "physical exam" entailed. Did he examine his big toe and it revealed no appreciable findings? Did he examine the patients toe and ear? Did he examine the entire body from head to toe and if so, it would still need to be medically necessary or relevant to why the patient is being seen.

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Aug 27th, 2010 - paulapreston 8 


Thank you! I totally agree.

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Aug 30th, 2010 - Codapedia Editor 1,399 

But, what was unremarkable?

I hope vitals are documented for the level 1. All exam elements must be described to be counted.

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