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1995 definition of Complete single-system exam

  1. #1
    Question 1995 definition of Complete single-system exam
    Medical Coding Books
    I was recently having a conversation with one of our neurosurgeons regarding e/m coding and he was asking about what would be considered a comprehensive exam in the neurosurgery practice. He was frustrated with the list of bullets from the 1997 guidelines so I told him about the 1995 guidelines. I told him that in the 95 DG, the wording for a comprehensive exam was "a general multi-system examination or complete examination of a single organ system." He felt satisfied that he is meeting his interpretation of a complete single organ system exam (even though he is not documenting all of the "bullets").
    My question is this: Is there any advice or guidance to determine what constitutes a complete single-system exam? If the doctor feels that it is complete, does that make it complete? I'm a little uncomfortable with that because I don't know if an independent auditor would agree with his self-assessment.
    Any help or advice would be greatly appreciated! Especially anything that points to guidance in writing so that I can go back to him armed with evidence.

  2. #2
    Milwaukee WI
    Default 1995 vague
    1995 guidelines are very vague .. which is why the 1997 guidelines came into being. But then the doctors had collective heart failure at the detailed documentation requirements in 1997, so 1995 was kept in place and people were given the choice of which to use.

    My advice is to have a list of bullets that your practice considers necessary for a complete neuro exam. And then to stipulate how many of those bullets are minimally required to be considered "complete single system exam."

    So start with the 1997 list ... JUST the NEURO part ... and ask your physician how many of those 16 bullets s/he feels constitutes a complete single system exam.

    Assuming the response isn't totally out of line (for example: 3), put that guideline into your compliance plan. And follow it.

    Any outside auditor will start by asking for your practice compliance plan/policy/standards. The auditor may not agree with your plan, but if you have it in writing you can at least make your case and show consistency.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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