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Is this an acceptable Physical Exam

trarut

Expert
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339
Location
Columbus, OH
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I am auditing a note (established patient) where the physician has documented for a 1/29 visit that the physical exam was performed 1/3....and then proceeds to give a nicely detailed physical exam.

Is this acceptable or does it rate no credit? I've never come across this before. My instinct was to give no credit but since it's an established patient, there's the added issue of needing only 2 of 3 elements anyway.

Insight (and links to references) is appreciated :)

Tracy
 

MnTwins29

True Blue
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East Greenbush, NY
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No

I base it strictly on what was performed and documented for the particular encounter - no exam given on 1/29, I will not count an exam for that visit - the one on 1/3 is used for the 1/3 visit not 1/29. Use the history and MDM for your e/m code.
 

trarut

Expert
Messages
339
Location
Columbus, OH
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I'm just getting back here to check the thread....it's been crazy busy at the office!

jmcpolin - The note has an HPI and MDM. I'm only questioning whether the Physical Exam can be counted when the physician notes that it was performed several days prior. I've never seen this before and my initial search for information didn't turn up anything about acceptable timeliness for a physical exam. (Hope that makes sense!)

MNTwins29 - My first reaction was to give no credit for the Exam. Then I thought I might be too hasty and that I should research it first. Thanks for the input!

Tracy
 
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