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Check list for exam

  1. #1
    Smile Check list for exam
    Medical Coding Books
    My Ortho doc wants to know if having a check list for his examination would be sufficient to add "bullets" to document a higher level of exam. He would dictate some to elaborate on the check list. It is permissable with the history that the patient fills out, I'm thinking it's permissable with the exam too, but am new at this and not certain. Can anyone give me references stating that's acceptable? Thx EG

  2. #2
    North Carolina
    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" 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.
    Rebecca CPC, CPMA, CEMC

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  3. Default
    Rebecca, I am looking for E/M auditing conferences. How would I find them?
    Nancy McGonigle

  4. #4
    North Carolina
    Hi Nancy,

    I have attended the AAPC's E/M seminars as well as McVey and Assoc. I have found both to be very informative. Our local Medicare carrier sponsor's free E/M auditing seminars but the travel distance can sometimes be an issue. In the meantime, maybe this information will be helpful until you can sign up for a seminar:
    Last edited by RebeccaWoodward*; 07-12-2008 at 12:31 PM.
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

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