Physician who uses "examination unchanged since last visit"?

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Shoshana
Posts: 85
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Wed Sep 26, 2018 3:29 pm

I have a physician who wants to say "examination unchanged since last visit". When I look back on previous notes, there may not have been an exam for several visits as they all say the same blurb. Would you give any credit for this? He is a specialist; and I am sure there are not many changes as he is treating chronic illness. His vital signs are always from the encounter's visit.
pedscoder
Posts: 26
Joined: Wed Jun 03, 2015 10:18 am

Tue Feb 05, 2019 2:00 pm

We have the exact same problem at our organization. We do not count this as an exam, as there is no proof in what the physician evaluated on that day. The only portion of the E&M that Medicare says is 'allowed' to be reviewed from previous notes is PFSH, as long as there is a notation regarding the DOS in which the provider is reviewing the prior information.
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