Counting skin exam elements, Dermatology


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We are having a debate after an audit and need clarification on counting elements of a skin exam- 97 guidelines.

In order to count "head, including face" (as listed on the specialty skin exam) Can just the face be examined for your 1 point, or does it have to document BOTH the head AND face were examined in order to get the 1 bullet point.
Same question for "Chest, including breasts and axilla"--Can the chest alone be examined, and count for your 1 point, or do all 3 of those areas need to be examined in order to get the 1 bullet point?

Example- chest, arms and legs were examined. Can the chest count as 1 point, or not at all because breasts and axilla are not listed.

Any clarification is appreciated!


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Here is a good specialty skin exam sheet

I audit a lot of encounters.

To answer your questions.

1. To get credit for the bullet point, you must document that you examined BOTH the head and face. (The word "including" is in the bullet description)

2. Same for chest, including breasts and axilla

The word including means you have to examine all the areas listed included within that bullet description.

I would give credit for just one, if the word "or" was used. For example, "head or face". But including is similar to "and" in this case and both must be documented.

Similarly, there is a bullet point for inspection of lips, teeth, and gums. When I audit, and I see just "lips" documented for the exam, they do not get credit for that bullet, because inspection of the teeth and gums was not recorded.