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Physical Exam Documentation help

  1. #1
    Default Physical Exam Documentation help
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    I'm an internal auditor and I have run into some exam documentation that I have not encountered before. The physician is using "denies" within the exam section which to me is more like ROS documentation, not physical exam.
    Wrists Denies swelling, denies tenderness
    Ankles Denies swelling, denies tenderness
    Feet Denies swelling, denies tenderness

    I feel like this could be a potential issue with an outside auditor. Am I completely off base?
    If not, would anyone be able to point me to information I could use to educate the physician?
    Hollee Hamilton, CPC, CEMA
    Last edited by hollee.hamilton; 11-07-2018 at 08:14 AM. Reason: left off example

  2. #2
    I can see your concern with the documentation as a possible reference to ROS instead of exam. This would be a great talking point with your physicians to explain how the documentation could be perceived by an outside auditor. Possibly a suggestion could be made for the provider to document the examination as "no appearance of swelling; no tenderness to the touch or based on movement."

    This is a good catch and it is always a good idea to suggest changes to eliminate any grey areas in documentation for audits and clarity.
    Chelle Johnson, CPC CPMA CDEO CEMC CPCO CPPM AAPC Fellow
    Billing/Coding/Credentialing/Auditing Coordinator

    20+ years experience in Medical Billing and Auditing

  3. #3
    Medical Billing
    Good advice! Thanks for the response

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