I have a Dr in my office who is seeing patient's with things like URIs, wheezing, OM, etc. He always has a normal exam on every illness. HPI and MDM support the illness, but there is never any thing abnormal noted in an exam.
We use eCW as our EMR system, so all the Drs have to do is push a button to drop their complete exam into the record.
I had been pushing back to have this Dr load addendums stating what was abnormal in the exams that supported the MDM, but he has been refusing to load addendums. My boss and I looked in several sources and cannot find anything at all that states the exam has to support the diagnosis, even though it seems like common sense.
Does anyone know where to find documentation stating that the exam MUST match the diagnosis, or am I just being unreasonable?
I know the rule says he only needs two out of three components, so the exam can pretty much be disregarded, but it drives me crazy that he's just dropping all these normal exams.
We use eCW as our EMR system, so all the Drs have to do is push a button to drop their complete exam into the record.
I had been pushing back to have this Dr load addendums stating what was abnormal in the exams that supported the MDM, but he has been refusing to load addendums. My boss and I looked in several sources and cannot find anything at all that states the exam has to support the diagnosis, even though it seems like common sense.
Does anyone know where to find documentation stating that the exam MUST match the diagnosis, or am I just being unreasonable?
I know the rule says he only needs two out of three components, so the exam can pretty much be disregarded, but it drives me crazy that he's just dropping all these normal exams.