Wiki 95 Guidelines Exam


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I am auditing E/M notes, and I am struggling with giving credit for a Detailed or Comprehensive exam under the 95 guides.

The physicians document at least 8 organ systems for every patient (obviously a template), regardless of what they are being seen for. There isn't much detail for any of them and I don't know if I should be giving credit for a Comprehensive exam just because there are 8 OS documented? Should there be more details for each organ system?:confused:

Looking for opinions from other E/M coders or auditors....
Leveling out your E/M code should not be based soley on your exam but your overall break down of each compnent, But as far as your specific question a statment of a OS being negative, I believe is sufficent enough to give them credit. You want to pay close attention the the systems being reviewed and make sure you have medical necessity.
I hope this helps...

Lynda wetter CPC
Must be more detail

I don't have this document in front of me right now, but I do recall reading that there must be some detail of the documentation for at least 2 or 3 of the systems to reach the detailed and/or comprehensive level. Just saying "negative" for 7 systems will not give a detailed exam - only EPF. As soon as I find that document, I will post, unless someone else does before I do!