- FAQs
- Admission and Discharge Services
- Advanced Care Planning
- Behavioral/Mental Health Services
- Chronic Care Management
- Complex and Chronic Care - HCPCS Code G2211
- Consultations
- Critical Care Services
- Documentation
- Emergency Department
- Examination
- Fee-For-Time Compensation Arrangements
- General E/M Information
- Global Period Services
- History
- IPPE and AWV Services
- Medical Decision Making
- New vs. Established Patients
- Nonphysician Practitioner Services
- Observation Services
- Preoperative Clearance
- Prolonged Services
- Provider Specialty
- Scribes
- Separately Identifiable Service
- Skilled Nursing Facility Services
- Frequently Asked Questions Smoking Cessation
- Split/Shared and Incident To Services
- Teaching Environment E/M Services
- Telehealth Services
- Time-Based Services
- Transitional Care Management
- Urgent Care
- Related Articles
As of 1/1/2023, CMS has eliminated prior specifications for the scope of examination and associated documentation in the outpatient office and hospital settings. The 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.
This rule also applies in the emergency department setting. A medically appropriate history and/or examination is a component of emergency department services at levels 99282-99285. Since 99281 does not require the presence of a physician or NPP, there is no history or examination component to 99281.
Examination
- Can either history or examination be used to level-set an E/M service.
Answer: Since history and exam elements are now based solely on medical necessity, neither of these may be used independently to level-set a visit. Excluding ED services (which are based solely on MDM), either total time spent or complexity of MDM are used to level-set a visit. For split/shared services in the inpatient setting, work performed and documented relative to performance of history or examination may be contributory, but not used exclusively, in defining the substantive provider.
- 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.
- 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.
Reviewed 4/15/2024