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Deferred Exam

  1. Default Deferred Exam
    Medical Coding Books
    Using 1995 guidelines, counting body systems, can you credit the phrase "exam deferred" as a body system? For example, if the physician dictates "rectal exam deferred", would that count as GI or does the physician get credit only when he actually performs the exam?

  2. #2
    no. deferred means he didn't do it. if he didn't do it, he doesn't get credit

  3. Default Deferred exam
    Thank you. I tend to agree. Is there anyone who thinks differently?

  4. #4
    I agree with NO. Deferred means it wasn't done, can't credit. I see this quite a lot, esp. with the rectal exam. It may have been deferred because it is not medically necessary - and medical necessity is required.
    Karolina, CPC, CPMA, CEMC

  5. #5
    According to Coding Answer Book, E/M guidelines pg 15315-16 "are coders allowed to "count" an exam bullet for a portion of the physical attemepted by the physician, but refused by the patient (for example, the rectal exam)? The answer is a very simple "no,"." It goes into more depth, just wanted to give you a resource.

  6. #6
    Default to mixitli
    Good stuff, but "deferred" is not necessarily because of the patient's refusal. I'm sure you feel the same way, since you also said "no".
    Karolina, CPC, CPMA, CEMC

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