Using 1995 guidelines, counting body systems, can you credit the phrase "exam deferred" as a body system? For example, if the physician dictates "rectal exam deferred", would that count as GI or does the physician get credit only when he actually performs the exam?
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Wiki Deferred Exam
- Thread starter NFBarner
- Start date
ARCPC9491
True Blue
no. deferred means he didn't do it. if he didn't do it, he doesn't get credit
Karolina
Guru
I agree with NO. Deferred means it wasn't done, can't credit. I see this quite a lot, esp. with the rectal exam. It may have been deferred because it is not medically necessary - and medical necessity is required.
Gainingknowledgedaily
Networker
According to Coding Answer Book, E/M guidelines pg 15315-16 "are coders allowed to "count" an exam bullet for a portion of the physical attemepted by the physician, but refused by the patient (for example, the rectal exam)? The answer is a very simple "no,"." It goes into more depth, just wanted to give you a resource.
Karolina
Guru
to mixitli
Good stuff, but "deferred" is not necessarily because of the patient's refusal. I'm sure you feel the same way, since you also said "no".
Good stuff, but "deferred" is not necessarily because of the patient's refusal. I'm sure you feel the same way, since you also said "no".