We are having a discussion here in the auditing department on whether or not an exam is required for a follow up exam. I quote "Two of the three key components (i.e. history, exam and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services.." I interpret that to mean you only need to document 2 of the 3 components. However, a few others interpret it to mean that you still need to document all 3 but choose the level based on the highest two I have been researching all morning and cannot locate anything that supports one interpretation over the other. I would love to get feedback regarding your interpretations. Thanks.

Pat Larabee, CPC