• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Documentation of Physical Examination

K

kimberlydegrazia

Guest
Messages
20
Location
Dartmouth, MA
For proper documentation of a physical exam for a Level 5 established patient, is it acceptable for a physician to dictate vital signs only and then state "The rest of the examination is the same"?

Thank you
 
no... what does the provider mean by this statement? If he means same as a previous exam, no you cannot do that... the only part of a visit that may be brought forward is the ROS part of history and even then the physician must document the date and location of the ROS being referenced as well as that it has been reviewed with the patient.
The exam is the providers hands on of the patient's current state, it cannot be referenced to in this manner
 
Debra is correct - you can't do that. I've seen doctors bill a level 5 service and say things like "The exam is completely unremarkable" or "exam is unchanged from the visit on 11/5" .... these phrases are not acceptable. You are allowed to say things like "Lungs - Normal" or "Eyes - Negative" but that's about as easy as it gets, you can't just say the entire exam is normal and expect to get credit for a Comprehensive examination.

....I'm all for efficient documentation, so I can see where your provider is coming from, but they are going to have to document just a little more.
 
You must log in or register to reply here.
Top