Check list for exam

eguest

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My Ortho doc wants to know if having a check list for his examination would be sufficient to add "bullets" to document a higher level of exam. He would dictate some to elaborate on the check list. It is permissable with the history that the patient fills out, I'm thinking it's permissable with the exam too, but am new at this and not certain. Can anyone give me references stating that's acceptable? Thx EG
 

RebeccaWoodward*

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I have asked this question at several e/m-auditing seminars and typically receive the same answer; "There's not a definitive answer, per se. It's left up to the discretion of the carrier". I do have a couple of providers who use this method but they do make entries that specifically record abnormal and relevant negative findings of the exam. I have strongly encouraged them to stay away from comments such as "abnormal" or "non applicable". If the finding is abnormal, they do elaborate.

Some of my providers use a template to document the exam. The template will provide a list of the "bullets"...as a reminder. More often than not, I find that the provider performs a detailed exam but fails to put it to paper. I hope others will respond. I would like to know what they encounter when they perform chart reviews.
 

RebeccaWoodward*

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