Billing For Established E/M Service

Can we bill for an established E/M service if the provider has not documented a Physical Exam or has stated "Physical Exam not done or deferred"?

re: Billing For Established E/M Service

Yes, you only need elements

re: Billing For Established E/M Service

I'm sorry, elements of what?
We are getting the HPI, Vitals, Assessment and Plan.
Sometimes no Physical Exam at all.
Sometimes it is states that the Physical Exam is being deferred or not done.
Either situation would still qualify for and established E/M (99212-99215)?

re: Billing For Established E/M Service

If you are getting the HPI and no review of systems you will be in 99212. The vitals are a component of the physical.
Established patients require 2 of three components (H; P; MDM).

re: Billing For Established E/M Service

You need 2 of the 3 elements documented