jewlz0879
True Blue
We use the 95' guidelines for our E&M coding and auditing. One of my physicians will document both body areas and organ systems under her Exam portion. It was my understanding that the coder is not suppose to combine those or count both to get the 8 required for a comprehensive level; it should be one or the other. My physician disagrees and does not find documentation stating it must be either body areas or organ systems documented.
This is what she said: Why would I have to say “respiratory” if chest is said and the clinical findings described could only be attributed to the respiratory system. We looked it up and Medicare does not require exact verbiage, just that the system/body area is described. Medicare requires one comment on each Organ system. If I say, chest is clear to auscultation with no weezes or rales, that can ONLY apply to the respiratory system.
Am I wrong? If not, is there documentation by CMS stating otherwise that I can give to her?
Thanks for any input/suggestions.
This is what she said: Why would I have to say “respiratory” if chest is said and the clinical findings described could only be attributed to the respiratory system. We looked it up and Medicare does not require exact verbiage, just that the system/body area is described. Medicare requires one comment on each Organ system. If I say, chest is clear to auscultation with no weezes or rales, that can ONLY apply to the respiratory system.
Am I wrong? If not, is there documentation by CMS stating otherwise that I can give to her?
Thanks for any input/suggestions.