Wiki Is this an acceptable Physical Exam

[trarut]

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

 

[trarut]

Bumping in hopes of a response....

 

[jmcpolin]

I am confused so you are saying he did not do a history or medical decision making?

 

[MnTwins29]

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]

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

 

[jmcpolin]

Ok now I understand if the exam was not performed on the dos 1/29 you can't use a prior exam.

 

[trarut]

Thanks! Sorry for the confusion.