I have asked this question at several e/m-auditing seminars and typically receive the same answer; "There's not a definitive answer, per se. It's left up to the discretion of the carrier". I do have a couple of providers who use this method but they do make entries that specifically record abnormal and relevant negative findings of the exam. I have strongly encouraged them to stay away from comments such as "abnormal" or "non applicable". If the finding is abnormal, they do elaborate.
Some of my providers use a template to document the exam. The template will provide a list of the "bullets"...as a reminder. More often than not, I find that the provider performs a detailed exam but fails to put it to paper. I hope others will respond. I would like to know what they encounter when they perform chart reviews.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join