Results 1 to 2 of 2

Exam Portion of Audit

  1. #1
    Default Exam Portion of Audit
    New Call-to-action
    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
    Default
    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

Similar Threads

  1. Exam Portion of E/M coding
    By 1formissy in forum E/M
    Replies: 4
    Last Post: 01-21-2015, 12:30 PM
  2. Exam Portion Help
    By AprilSueMadison in forum E/M
    Replies: 3
    Last Post: 10-02-2013, 05:56 AM
  3. Exam portion of note
    By Lynda Wetter in forum E/M
    Replies: 1
    Last Post: 02-22-2013, 08:26 AM
  4. Exam portion when 3 out 3 must me met
    By Mklaubauf in forum E/M
    Replies: 3
    Last Post: 07-14-2009, 03:25 PM
  5. 1997 exam portion
    By yvette31 in forum E/M
    Replies: 1
    Last Post: 04-03-2008, 10:33 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.