emccarty
Guest
Hello,
I was recently having a conversation with one of our neurosurgeons regarding e/m coding and he was asking about what would be considered a comprehensive exam in the neurosurgery practice. He was frustrated with the list of bullets from the 1997 guidelines so I told him about the 1995 guidelines. I told him that in the 95 DG, the wording for a comprehensive exam was "a general multi-system examination or complete examination of a single organ system." He felt satisfied that he is meeting his interpretation of a complete single organ system exam (even though he is not documenting all of the "bullets").
My question is this: Is there any advice or guidance to determine what constitutes a complete single-system exam? If the doctor feels that it is complete, does that make it complete? I'm a little uncomfortable with that because I don't know if an independent auditor would agree with his self-assessment.
Any help or advice would be greatly appreciated! Especially anything that points to guidance in writing so that I can go back to him armed with evidence.
Thanks!
Elizabeth
I was recently having a conversation with one of our neurosurgeons regarding e/m coding and he was asking about what would be considered a comprehensive exam in the neurosurgery practice. He was frustrated with the list of bullets from the 1997 guidelines so I told him about the 1995 guidelines. I told him that in the 95 DG, the wording for a comprehensive exam was "a general multi-system examination or complete examination of a single organ system." He felt satisfied that he is meeting his interpretation of a complete single organ system exam (even though he is not documenting all of the "bullets").
My question is this: Is there any advice or guidance to determine what constitutes a complete single-system exam? If the doctor feels that it is complete, does that make it complete? I'm a little uncomfortable with that because I don't know if an independent auditor would agree with his self-assessment.
Any help or advice would be greatly appreciated! Especially anything that points to guidance in writing so that I can go back to him armed with evidence.
Thanks!
Elizabeth