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Exams-help please

  1. #1
    Default Exams-help please
    Medical Coding Books
    Good Morning fellow coders,

    I started last week in a new urology practice. I have been certified for 14 years and the person who is training me is trying to tell me that the phy does NOT have to have GU as part of the exam. I just wanted to make sure that I am not missing anything here....I have always been told that they HAVE to have the pertinent organ listed in an exam expecially in specialties. Is this not correct? I do not want to make waves in a new job but I also do not want to be resp for this company not coding correctly. Please help

    Thank you!!

  2. #2
    Augusta, Georgia
    Hi.. I checked with one of my colleagues who has extensive E/M and practice management experience.

    She stated that ... "The exam system of the presenting problem must be in the PE. Since it is a Urology practice, the presenting problem would be a GU one, therefore that portion is the PE is required."

    Also she referenced:

    FAQ 9. How are the Exam components defined?

    Exam: documentation may be body area or organ system based, except a comprehensive exam which is based on organ systems only.

    The extent of documentation will depend on the nature of the presenting problem. Both CMS and CPT use the following definitions:

    Problem focused: a limited examination of the affected body area or organ system.

    Expanded problem focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

    Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

    Comprehensive: a general multi-system examination or a complete examination of a single organ system.
    Michelle Cowart, MPH, RHIA, CCS, CPC, CPC-I, CIC
    AHIMA Approved ICD-10-CM/PCS Trainer/Ambassador
    Director of Operations, All About Coding, LLC
    Licensed AAPC-PMCC Site
    CPC Prep Review, Online Medical Coding Education
    Inpatient and Outpatient online coder training

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