Wiki E&M Exam no positive findings

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peanutbutterkisses

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I'm auditing a provider who is documentating the same comprehension exam with negative findings despite the presenting symptoms. Can anyone tell me of a specific guideline that states that the exam must address the positive findings of the chief complaint.
My coworkers disagree with my concern for cut/paste and medically necessary exam because exams for established patients can be tossed.
 
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There isn't a guideline for this - coding rules say that you code from what is documented, and there aren't guidelines to tell coders when or which documentation to disregard if it appears to be inaccurate or medically unnecessary. If a provider is documenting inaccurate information, or making inappropriate use of cut and paste, that is a documentation quality issue and should be addressed separately with the provider or with your manager. I've always advocated that coders cannot correct provider documentation issues simply by down-coding services - that doesn't correct the root cause of the problem.
 
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Did you look at the 95 and 97 E/M documentation guidelines? I swear I saw something in there about this. Also, I just watched a workshop via AAPC (I paid for it) related to auditing E/M levels and the speaker clearly stated that the exam must have an element that shows a relationship to the presenting problem.
 
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I don't remember anything that states that the exam must correspond to positive findings in the HPI/CC. But look at page 10 of the 97" "The extent of the exam performed...is dependent upon...the nature of the presenting problem/s". The very fact that there are four separate exams is a clear indication that CMS expected the exams to vary depending upon the nature of the presenting problem/s. After reading the official 1995 and 1997 guidelines several times it hit me that CMS was under the impression that physicians would not document anything that was not "Medically Necessary". However they were wrong if this was their assumption. They just created the documentation "hoops' necessary to justify one code over another. Since medical necessity is the basis for everything performed/documented, a Comprehensive exam on every patient shows just the opposite, that there is no medical necessity. And just because one of the key components can be "tossed" for an established patient does not justify performing a comprehensive exam on every patient. Question. Does every patient have a comprehensive History documented as well? With EMR's and it basically walking the clinical staff to document "everything" rather than what is medically necessary, I am a firm believer that the E/M should not be higher than the MDM portion which is basically what we are moving to next year. I share your concerns for the co-workers who don't see anything wrong with "copy and paste".
 
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