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As of 1/1/2021, CMS has eliminated prior specifications for the scope of examination and associated documentation in the outpatient and/or office setting (CPT Code Range 99202-99215). In the outpatient and office settings, a provider is expected to perform and document a medically necessary and relevant examination based on the patient’s presenting complaint(s) and/ or known history and on the examiner’s observations of the patient’s condition.

In the emergency room and all inpatient settings, examination requirements remain unchanged and are subject to CMS E/M 1995 or 1997 guidelines. Refer to Examination Prior to 12/31/2020 for guidelines during that period.

Examination On or After 1/1/2021

  1. Please define the CMS rule for the scope and level of a physical examination performed during an E/M service in the office or outpatient setting.

    Answer:
    In the office or outpatient setting, the scope and level of a physical examination is dictated by both the patient’s presenting complaint and/or clinical status and by the examiner’s medical judgment in determining what scope of examination is medically indicated. In general, a straightforward complaint requires an examination of the affected body area or system; in the presence of known comorbidities or new clinical observations, the examiner may perform a more comprehensive examination and must clearly document the medical necessity of the enhanced examination. For services in the outpatient and office setting (as of 1/1/2021) documentation must always support the medical necessity of the examination and the associated time spent, since the service may be coded based on time. Here are two examples
    • A patient with no known comorbidities presents with a minor hand laceration that requires simple repair. A simple, brief examination would be considered medically necessary unless there were other documented factors supporting a more comprehensive and lengthy examination.
    • Patient with known hypertension and atrial fibrillation, who is on an anticoagulant regime, presents with a minor hand laceration relative to a fall and questionable loss of consciousness. Although the hand laceration appears to be a simple problem, a broader scope of examination may be considered clinically appropriate. Added 1/20/2021
  1. Is a physical exam required documentation for billing an inpatient discharge E/M service (CPT codes 99238/99239)?

    Answer: A physical examination is not a required component of an E/M discharge service (CPTs 99238‒99239), unless indicated by the patient’s clinical status on the date of discharge. The note must reflect a discussion of the hospital stay and plans for post-discharge care, preparation of records and prescriptions and referral forms as necessary. Revised 1/20/2021
  1. When a patient returns for a follow-up visit for a complaint previously and successfully treated, is that subsequent visit considered to be medically necessary?

    Answer:
    A follow-up visit may be considered medically necessary, when the provider plans to evaluate effectiveness of prior treatment. The fact that the patient no longer has a complaint does not negate the medical necessity of the visit. Here are two differing examples:
        • A patient previously seen for headaches and found to be hypertensive, with medication prescribed, now returns symptom-free for blood pressure evaluation. This visit would be medically necessary to evaluate the patient’s response to medication.
        • A patient previously seen for a common cold now returns for a follow-up visit with no complaints. Since the original visit was for a self-limiting condition and no medical treatment was initiated, the medical necessity for a follow-up visit is questionable and should be carefully considered. Revised 1/20/2021
  1. What scope of examination is required for a detailed or comprehensive level of examination?

    Answer:
    There are no specific CMS requirements for the scope or detail of an examination in the outpatient or office setting, at any level. The scope of examination is determined by the examiner, based on medical necessity relative to the presenting complaint and to other known comorbidities that may require the examiner’s attention. Revised 1/20/2021

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Examination On or After 1/1/2021
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