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Physical Exam - I am performing an audit

  1. #1
    Default Physical Exam - I am performing an audit
    Medical Coding Books
    I am performing an audit, and on my audit tool, it lists Body Areas and Organ systems. Can I count the total of both. So for example, I have 4 body areas: Head, Chest (breasts), Abdomen, and extremity... Then for my organ systems I have: Constitutional, card, resp, and lymph... Can I count that as 8 systems?

    Thanks,
    Kristen Richard, CPC

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default 1995 guidelines
    For a comprehensive exam, following the 1995 guidelines, the physician must document examination of 8 organ systems. Body area do NOT count for the comprehensive exam at all.

    For EPF - Limited exam of the affected body area or organ system, plus other related or symptomatic organ systems.

    For DETAILED - Expanded exam of the affected body area or organ system, plus other related or symptomatic organ systems.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default
    nope, its one or the other, body area or organ system, you cannot mix

  4. #4
    Location
    Daytona Beach, FL
    Posts
    742
    Default
    We have been instructed by Highmark Medicare Services, our MAC, that you cannot combine body areas and sytems for any level. It is one, or the other. However, depending on what you have for documentation for the body areas, they can also apply to the organ systems - i.e. Abdomen = GI, Chest (breasts) = Integumentary, Extremities = Muscular Skeletal or cardio, Head = Eyes, Ears, Nose, Mouth, Neck = Lymph etc., - so if your documentation would support this, then you would have 8 systems.
    Jodi Dibble, CPC

  5. Default
    How are you defining an "extended exam" under 95 guidelines?

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