Exam Elements

[wynonna]

We have a provider who lists the same exam elements and findings for every visit in an Internal Medicine Practice. It's almost like this provider uses a template and doesn't tailor it for specific complaints or findings particular to each patient.
Is that ok or is that a red flag for an audit?
Thanks

 

[danskangel313]

We have a provider who lists the same exam elements and findings for every visit in an Internal Medicine Practice. It's almost like this provider uses a template and doesn't tailor it for specific complaints or findings particular to each patient.
Is that ok or is that a red flag for an audit?
Thanks

The main thing keep in mind is that exam elements should be relevant to the CC. So if a patient comes in with a cold, for example, and the provider examines all 4 extremities, that would be a bit odd unless there's a medically necessary reason (that is documented) to examine those areas.

This is an older article, but has some pretty good information:
"In other words, copying and pasting, pulling forward information, and the use of macros could all be defined as cloning."
https://www.aapc.com/blog/29747-cloning-address-the-elephant-in-the-room/

 

[wynonna]

Exam elements and separate topic: Advanced Care directive--999497

Thank you for your thoughtful answers to my questions and the links and sources you provide. On another topic, in our practice we have been billing Z75.8 for "other problems related to medical facilities and other health care" for 99497 Advanced Care Planning, aka Moulst.
I have not heard of any denials with this ICD10. We must attach modifier -33 to CPT and Medicare is good at reimbursing for advanced care directives. I've been billing when at least 16 minutes (more than half the minimum of 30 minutes) is done. I always have to remind the providers that it is time-based and minutes spent counseling patients and family members must be documented. Hope this helps in some way since I've seen this question posted.