Wiki 95 guideline exam audit question

[hbailey42]

What do I look for when auditing documentation using the 95 guidelines when I look at the hema/lymp/immun for the exam portion of the audit? I want to make sure I am giving credit for what the doctor examines. I know lymph nodes or thyroid would count. How would the doctor address the hema in the exam? My physician is stating allergy is part of the exam not ROS.

Thanks for any help in clarifing this issue,
Heather

 

[FTessaBartels]

Example needed

Can you give us an example of a scrubbed note so we can see just where the issue lies?

It's hard to come up with something off the top of my head that would be an example.

But since Hematologic/Lymphatic/Immunological are all considered "one" system for the exam portion of 1995 guidelines, meeting any one of them (i.e. lymph nodes) would get you that "system."

By the way ... the thyroid does NOT fall in the lymphatic system, but in the "neck."

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[hbailey42]

I guess that is what I am asking what would be considered the hema/immun on the exam portion? What do I look for?

I am being told that Allergy can be used here but I thought the physician had to physically exam the patient in order to get credit so how do they examine hema/immun?