Wiki 1995 Physical Exam body vs. system

[Vicky Green]

I've been researching the Physical Exam (PE) requirements under Medicare's 1995 guidelines for a complete PE. I even asked Noridian (Medicare Carrier) for their clarifiaction on whether comments on body areas count. For example, Neck: no JVD, flat neck veins, when the DR already used Cardiovascular as a system. I listed Noridian response below, its says no, then yes..?!! Can you use body areas, w/physical comment and get it counted with along your organ system comments to hit the 8 needed??? Help!

Noridian Response:
According to the 1995 guidelines eight organ systems must be examined. If body areas are examined and counted, they must be over and above the 8 organ systems. Organ systems or body areas, or a combination of both may be used. However, credit will not be given for one area of the body twice. As an example: credit won't be given for both abdomen in body areas and gastrointestinal in organ systems.

 

[FTessaBartels]

Organ Systems ONLY for Comprehensive Exam

To count as a comprehensive exam under the 1995 guidelines the physician must document examination of at least eight of the following 12 organ systems:
Consitutional
Eyes
Earns, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunological

Makes no difference what the physician "calls" it - if he calls it anything at all. As long as eight of these 12 organ systems are documented you have a comprehensive exam under 1995 guidelines.

Noridian's answer is IF body areas are counted they must be OVER AND ABOVE the 8 organ systems. (emphasis added by FTB)

So in your specific example ... Yes, these remarks under the title "NECK" are cardiovascular system. But you can't count CV twice if he also documents "RRR, no MRG" somewhere else in the note.

Hope that helps.

F Tessa Bartels, CPC, CEMC