Deferred Exam

NFBarner

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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?
 

NFBarner

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Deferred exam

Thank you. I tend to agree. Is there anyone who thinks differently?
 

Karolina

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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.
 
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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

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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".;)
 
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