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Specific or assumed?

  1. Default Specific or assumed?
    Exam Training Packages
    While learning E/M. The reports i'm practicing show a doctor doing exams that involve certain checks. The paperwork i'm learning from shows me items such as "cardiovascular" and then lists a few bulleted items with some examples.

    Are these examples the ONLY things allowed to be mentioned in the report to earn a point? I am seeing doctors talk about certain things, and the term does not show up in my example, so I am reluctant to assign a point unless I see that term, or a meaning that describes that term.

    Such as "extraocular nerves in tact" and "extraocular movements in tact" I am assuming those are the same thing, although i've been taught not to assume, and that if it isn't documented right, don't assign a point to it. I hope this makes sense, because it is really slowing me down, and i'm finding that i am getting alot of these wrong.

    I also understand that i will get alot wrong at first, I just want to know WHY i am getting them wrong, so that i can get a deeper understanding of these things soon... Thank you.
    Adam L. Shoop CPC
    You will be successful in whatever you choose to do,
    and light will shine on the path ahead of you. Job 22:28

    Only because of God, my father, and Jesus Christ,
    did I make it into this field so smoothly. Thank you God!

  2. Default
    The answer depends on if you are using 1995 or 1997 (specialty) guidelines. If you are using 1997 specialty guidelines then you need to follow the bullets. '95 is less specific-so I wonder if these are examples given as part of your training.

    Here's a link for 1997 e/m guidelines:
    http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf

    This link is for 1995:
    http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf
    Dee
    CPC, CPCO, CPMA, CPCD

  3. Default
    Thanks Dee, that was helpful resource. Alot of my issue stems from if a doctor says, "Cardiovascular all normal" Does it get a bullet, or does the doc need to specify that the heart was auscultated to get the point, or that a murmur was identified or not identified. Should there be a keyword described in the documentation in order to qualify for the point. I'm confusing myself again now...
    Adam L. Shoop CPC
    You will be successful in whatever you choose to do,
    and light will shine on the path ahead of you. Job 22:28

    Only because of God, my father, and Jesus Christ,
    did I make it into this field so smoothly. Thank you God!

  4. Default
    On page 13 of http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf

    !DG: Specific abnormal and relevant negative findings of the examination of
    the affected or symptomatic body area(s) or organ system(s) should be
    documented. A notation of "abnormal" without elaboration is
    insufficient.
    !DG: Abnormal or unexpected findings of the examination of any
    asymptomatic body area(s) or organ system(s) should be described.
    !DG: A brief statement or notation indicating "negative" or "normal" is
    sufficient to document normal findings related to unaffected area(s) or
    asymptomatic organ system(s).
    Dee
    CPC, CPCO, CPMA, CPCD

  5. #5
    Location
    Kansas City, MO
    Posts
    431
    Default
    Quote Originally Posted by AdamShoop View Post
    Thanks Dee, that was helpful resource. Alot of my issue stems from if a doctor says, "Cardiovascular all normal" Does it get a bullet, or does the doc need to specify that the heart was auscultated to get the point, or that a murmur was identified or not identified. Should there be a keyword described in the documentation in order to qualify for the point. I'm confusing myself again now...
    Adam, it will depend on whether or not you are using 95 or 97.

    If using 95, the guidelines are really non-specific, and so it is possible with the "all normal" statement, the dr could get credit for examining the CV system.

    97 guidelines are more specific, and give you the specific bullets to meet.

    Do you know if this audit tool ("paper you are learning from") is based on either 95 or 97 guidelines?
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

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