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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.
    Musculoskeletal:
    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?
    Thanks!
    Hollee Hamilton, CPC, CEMA
    Last edited by hollee.hamilton; 11-07-2018 at 08:14 AM. Reason: left off example

  2. #2
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    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
    Default
    Medical Billing
    Good advice! Thanks for the response

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