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Exam Portion of Audit

  1. #1
    Default Exam Portion of Audit
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    I work for an orthopedic office and I have a question about a physician's documentation and what I can count in the exam section of an audit based on the wording in the documentation. The physician frequently uses the phrase "Range of motion, muscle strength, and stability of the feet were otherwise intact". He says he should get 6 points for this in the exam section (RT Leg ROM, strength, and stability; LT Leg ROM, strength, and stability). The wording "otherwise intact" is throwing me off..... is it okay for the physician to put this and it counts, or should he say something like "are within normal range"?

  2. #2
    Medical Billing
    The sentence "otherwise intact" is a phrase commonly used by providers to notate that this part of the exam was examined and found benign. I would count this phrase towards exam element credit, as long as the rest of the sentence makes sense and is appropriate. Of course, if the provider is looking for areas of improvement of his/her documentation, then perhaps expand with "both feet" or even "within normal limits".

    However, if I was to audit that segment and based on the wording, I would accept "otherwise intact" as you have presented.
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

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