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RE: Physical Exam/Comprehensive

  1. Default RE: Physical Exam/Comprehensive
    Medical Coding Books
    Our chart notes give the doctor the opportunity to check off the systems that they have examined and to note the positive and negative entries. I had hoped that revising the form would help them keep track of the examination critieria. The problem is that they often do not check off all of the systems on the initial exam chart notes, but they later dictate the H & P on a different day then the patient was in the office and on the H & P they do cover the appropriate systems. Keep in mind that the patient has not returned to the office in between the first visit and the surgery. They also do not note on their chart notes that they are doing an H & P for the surgery. My question is can I use the dictated H & P as a criteria for the initial visit exam requirement. I guess my concern is that even though I know that they are using the first visit notes as a guideline the H & P is always dictated just before the surgery and it does not always reflect what they have checked off on the inital notes, and the H & P is also dated a different date then the initial visit.



  2. #2
    Are you charging for 2 different visits?

    If the H&P is dictated days later than it was done but still for the same visit you would use that in addition to any written documentation for that date of service.

    I'm not sure I understand your situation completely,

    Laura, CPC, CEMC

  3. Default
    No, I am not charging for two different visits. It is just that the documentation noted on the initial visit (doctor checks off systems that were reviewed) and lists positives and negatives is often different than the H & P that is dictated at a later date. He does not alway document all of the systems reviewed on the initial visit but they are included on the H &P that is dicated some days later. The patient has not returned for another visit, so my concern is matching the original documentation on the first date with the H & P that is completed some days later and has a different date. I hope that it makes sense.

    Thanks for your reply!!


  4. #4
    They wouldn't have to match up, as long as they are for the same date all the info counts toward his level. He should reference the form by name and date though in his dictation.

    Laura, CPC, CEMC

  5. #5
    Milwaukee WI
    Default Date of Service
    THe date of service of his dictation (H&P) is the date he saw the patient ... as long as it's within the specified timeframe for the hospital's guidelines (usually within 30 days) he should be fine.

    His H&P dictation should have:
    Date of service: mm/dd/yy (the date he actually saw the patient in the office)
    Date of admission: mm/dd/yy (the date the patient is to be admitted)
    Date of scheduled procedure: mm/dd/yy (may be same as date of admission, or a day later).

    The surgeon should reference by form name and date the check-off chart note (which should also be signed & dated) so that s/he gets full credit for all the work done on that initial visit.

    Of course it would help if on actual admission, the surgeon briefly went over the dictated H&P (which was done some time before the admission) to ensure there are no significant changes.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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