Exam and time in a visit | Documentation requirements in E/M services

Question:

For an established patient, if I don’t document a physical exam, am I required to say that the visit was a counseling visit and document time?

Answer:

No. And, it would be incorrect to do so, if counseling did not dominate the visit.

Established patients require two of the three key components of history, exam and medical decision making. Neither CPT^® nor CMS define which two must be documented. Many established patient visits have only vital signs or an observational exam.  In those cases, the visit may be based on the key components of history and medical decision making. These two components alone determine the level of service.

The absence of an exam does not mean that the requirements for using time were met.

Counseling determines the code when more than 50% of the face-to-face time is spent in counseling, as defined by CPT^®. In that case, time must be the determining factor, according to CPT^®.

Why if there is no exam wouldn’t the visit always be counseling?

Because the practitioner is performing the activities related to history and MDM, and this is not the same as counseling. The practitioner is eliciting the HPI and ROS, and confirming past medical and social history.  There may be diagnostic or other objective data to review.

And, then the practitioner performs medical decision making activities. MDM includes assessing the status of the patient’s condition, reviewing the current plan and its effectiveness and confirming the existing treatment plan or revising the treatment plan.

This isn’t synonymous with a counseling visit, as defined by CPT^®. It would be incorrect to code these as counseling visits, when the documentation did not clearly describe counseling and that more than 50% was spent in the counseling.

CPT^® references:

The first three of these components (history, examination, and medical decision making) are considered the key components in selecting a level of E/M services.

The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors in the majority of encounters. Although the first two of these contributory factors are important E/M services, it is not required that these services be provided at every patient encounter.

Also see Documentation Guidelines for Exam and Everyday Coding.

Or browse more articles and tips on documenting time and the three key components.