I am not a physician, so I do not second-guess my physicians on the medical necessity of the exams they perform ...
We do audit our physician's documentation and those who are ALWAYS performing a comprehensive exam may be queried as to the medical necessity of same for certain diagnoses.
Remember, the exam is only one element of determining the level of service. History and Medical Decision Making are the other two components.
It is the responsibility of the physician to document what s/he does. It is the responsibility of the coder to translate that documentation into the code.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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