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New pt exam

  1. Default New pt exam
    Medical Coding Books
    With a new pt my Doc dictates that a full musculoskeletal examination was documented on our office form. If he dictates everything else correct would that exam count for a 99204 or does he have to a exam of the 10 organs for the 99204. The sheet he uses has Systems and Body areas that are the examination. The Doctor is a Orthopedic Surgeon so the exam would be his specialty. He never does a exam of all the organ parts. Thanks for the help I need it Cora We use the 95 guidlines
    Last edited by grandmacora; 10-24-2011 at 09:13 AM.

  2. #2
    Milwaukee WI
    Default 1995 guidelines
    The 1995 guidelines DO allow "a complete single system specialty exam" to be counted as "comprehensive." However, the guidelines don't give you any clue what that means, or how to determine if the exam you have is "a completely single system specialty exam."

    I tell my specialists (we use 1995 also), that they should include in their office protocol a description of what constitutes "a complete single system specialty exam" .... is thoroughly examining only the affected limb sufficient? How about the affected limb and the contralateral side? If patient presents with a fractured upper extremity do they need to check the lower extremities? You see the dilemna ...

    Make THEM quantify it, and add that to your protocol for internal audit.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    I have to agree, if you are going to go by 1995 guidelines I would set up an office "policy." Because 1995 guidelines are so vauge on what that means I always suggest to my physicians that they look over the 1997 single organ exam to see what is expected out of them to meet that. I like that the 1997 guidelines are more cut and dry when it comes to the specialists work!
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

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