Question about 1995 exam guidelines

coder25

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Hello,

I am new at coding and I have come across a question concerning the 1995 medicare guidines that I am confused about. :confused:

I work for a general surgery office and they state that it is okay for include the body areas in the examination to count for a comprehensive examination, however, upon reading posts here and doing research, it states that only the organ areas count for comprehensive. Is this true?? If so, how would I count an exam for a NP with breast cancer and the doctor includes 7 organ systems...would this be considered only a detailed exam???

Also in the organ systems section there are GI and GU part..is this another name for the body abdomen area and the genatalia/groin/buttocks??

Any help anyone can give to help clear this up for me, would be greatly appreciated!
 
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Use 97 guidelines

The 95 guidelines allow you to use body areas up to the detailed exam section. But there are only 7 body areas, and you need 8 of 12 systems to equal a general multi-system exam (required for "Comprehensive" exam). The 12 systems for physical exam are different from the 14 systems for ROS.

Don't get bogged down in the organization of your physcian's dictation. Few notes are perfectly laid out. And physicians may interchange verbiage based on the way they are thinking about the presenting problem.

I would break down the actual phrases dictated by the physician using the 97 guidelines ... that will let me know which systems are involved. If there are 8 systems, you can use the 95 guidelines to reach a comprehensive exam level.

If you post a scrubbed exam, I can help you identify the systems.

F Tessa Bartels, CPC, CPC-E/M
 
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