97 Guidelines Help

maine4me

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Can someone please clarify this something for me? I generally use the 95 guidelines, however I am now auditing some of notes and want to review using both sets of guidelines. In the exam portion for the 97 guidelines, if it is is a mult-system exam are the bullets on the grid the only things credit is given for in each system? And you may have more than one bullet in each system, correct?

I just want to make sure I am using this correctly.
 
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1997 guidelines

Unlike the 1995 guidelines, the 1997 guidelines are extremely specific in what must be documented for each level of exam. ONLY those items outlined by a bullet can count. And you can count as many bullets as are documented.

So, for example, in pediatrics, especially with infants, it is common to note that the "anterior fontanelle is soft and flat" ... but this item isn't anywhere on the bullets for 1997 guidelines, so the physician gets no credit for it (though it is an important element in an infant's exam).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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