Specific or assumed?

AdamShoop

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While learning E/M. The reports i'm practicing show a doctor doing exams that involve certain checks. The paperwork i'm learning from shows me items such as "cardiovascular" and then lists a few bulleted items with some examples.

Are these examples the ONLY things allowed to be mentioned in the report to earn a point? I am seeing doctors talk about certain things, and the term does not show up in my example, so I am reluctant to assign a point unless I see that term, or a meaning that describes that term.

Such as "extraocular nerves in tact" and "extraocular movements in tact" I am assuming those are the same thing, although i've been taught not to assume, and that if it isn't documented right, don't assign a point to it. I hope this makes sense, because it is really slowing me down, and i'm finding that i am getting alot of these wrong.

I also understand that i will get alot wrong at first, I just want to know WHY i am getting them wrong, so that i can get a deeper understanding of these things soon...:D Thank you.
 

AdamShoop

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Thanks Dee, that was helpful resource. Alot of my issue stems from if a doctor says, "Cardiovascular all normal" Does it get a bullet, or does the doc need to specify that the heart was auscultated to get the point, or that a murmur was identified or not identified. Should there be a keyword described in the documentation in order to qualify for the point. I'm confusing myself again now...:D
 

DeeCPC

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On page 13 of http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf

!DG: Specific abnormal and relevant negative findings of the examination of
the affected or symptomatic body area(s) or organ system(s) should be
documented. A notation of "abnormal" without elaboration is
insufficient.
!DG: Abnormal or unexpected findings of the examination of any
asymptomatic body area(s) or organ system(s) should be described.
!DG: A brief statement or notation indicating "negative" or "normal" is
sufficient to document normal findings related to unaffected area(s) or
asymptomatic organ system(s).
 

LindaEV

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Thanks Dee, that was helpful resource. Alot of my issue stems from if a doctor says, "Cardiovascular all normal" Does it get a bullet, or does the doc need to specify that the heart was auscultated to get the point, or that a murmur was identified or not identified. Should there be a keyword described in the documentation in order to qualify for the point. I'm confusing myself again now...:D
Adam, it will depend on whether or not you are using 95 or 97.

If using 95, the guidelines are really non-specific, and so it is possible with the "all normal" statement, the dr could get credit for examining the CV system.

97 guidelines are more specific, and give you the specific bullets to meet.

Do you know if this audit tool ("paper you are learning from") is based on either 95 or 97 guidelines?
 
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