Dianna Peltier, CPC


Best answers
Could some one give me some advice. I am doing an audit on a cardiologist using the 97 guidelines. I am getting different opinions on a comment the doctor is making in his exam. The following is the excert from his documentation.

Neurologic: Grossly Normal. Sensory, motor and reflexes equal bilaterally.

What would the bullets be for these? He is trying to count 4 bullets from this statement. We are at a disagreement on what to count as a bullet and what bullet they would be.

Thanks for anyone's help.
E&M audit

Dianna, you say you are doing an audit for a cardiologist. It sounds like the exam was documented with other organ systems other than cardiovascular, and the area in question (Neuro: is only conunted as one bullet, according to what he has documented ). It sounds as if he only examined the sensation of the nerves because looking at the DG under neuro: one bullet is to test the crainal nerves w/notation of any deficits,2nd bullet element is: exam of DTR with notation of pathological reflexes, 3rd bullet:exam of sensation. I would show the provider just what the DG for 97 are for elements of an exam hope this helps, I know your frustration and remember not documented, not done.
Thank you for the input. I have tried to get our specialists to dictate based on their specialty exam but it has been an uphill fight. Our physicians have been taught to dictate based on the multi-specialty exam and I think this really hurts some of our doctors. I have learned to look to the 95 guidelines when this happens and usually the doctors will meet their levels that way. I will show the physician the DG for Neurologic and advise him to change his dictation habit or to expand on what he is documenting. Thanks again...