E&M coding of exam

elzab

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The doctor and I are having a disagreement with the exam part of the 1995 guidelines, my impression from medicare is that the exam should reflect on the chief complaint. Example New patient comes in complaining of back pain, the doctor has documented a complete exam ent,eyes, cardio,resp, gi, gu, musculo, skin, neuo, and psych. As per my understanding the exam should reflect on the chief complaint, truly not necessary to do a complete exam is this correct or incorrect?
 
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Milwaukee WI
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Coder vs Clinician

I am not a physician, so I do not second-guess my physicians on the medical necessity of the exams they perform ...

HOWEVER ...

We do audit our physician's documentation and those who are ALWAYS performing a comprehensive exam may be queried as to the medical necessity of same for certain diagnoses.

Remember, the exam is only one element of determining the level of service. History and Medical Decision Making are the other two components.

It is the responsibility of the physician to document what s/he does. It is the responsibility of the coder to translate that documentation into the code.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

gailmc

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I agree with Tessa. It is hard to hint to a provider that an exam element does not meet medical necessity when we are not physicians. What we can do is recognize trends and alert providers to trends in their documentation and educate them on any RACs or CERTS that Medicare has done recently.
 
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