kacunn
New
I need this broke down as we are being audited by insurance. What is the difference between the Palpation of scalp ect.
and the inspection of the 10 anatomic areas?
I go to audit this out and I am thinking that I am double dipping when I go and start counting the HEAD AND FACE ect. as to me I already did that with the first bullet and if feels like I am double dipping? I do not understand what the difference is between this skin exam and palpation. Anyone have any pointers on how to better understand this. thanks in advance.
Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities
Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:
Head, including the face z Neck
Chest, including breasts and axillae
Abdomen z Genitalia, groin, buttocks z
Back
Right upper extremity
Left upper extremity
Right lower extremity
Left lower extremity
NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements. Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis. Note: The Head/Face, Respiratory, Chest (Breasts), Genitourinary, and Musculoskeletal systems/body area are not integral parts of this specialty exam. (Enter the number of circled bullets in the boxes below. Then circle the appropriate level of care.) Answer the following two questions. If both answers are "yes," the appropriate level of exam is comprehensive. Was at least one bullet documented in each unshaded box? Yes No Was each bullet in each shaded box documented? Yes No z z z z z
and the inspection of the 10 anatomic areas?
I go to audit this out and I am thinking that I am double dipping when I go and start counting the HEAD AND FACE ect. as to me I already did that with the first bullet and if feels like I am double dipping? I do not understand what the difference is between this skin exam and palpation. Anyone have any pointers on how to better understand this. thanks in advance.
Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities
Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:
Head, including the face z Neck
Chest, including breasts and axillae
Abdomen z Genitalia, groin, buttocks z
Back
Right upper extremity
Left upper extremity
Right lower extremity
Left lower extremity
NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements. Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis. Note: The Head/Face, Respiratory, Chest (Breasts), Genitourinary, and Musculoskeletal systems/body area are not integral parts of this specialty exam. (Enter the number of circled bullets in the boxes below. Then circle the appropriate level of care.) Answer the following two questions. If both answers are "yes," the appropriate level of exam is comprehensive. Was at least one bullet documented in each unshaded box? Yes No Was each bullet in each shaded box documented? Yes No z z z z z