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
- 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