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examination guidelines

  1. Default examination guidelines
    Exam Training Packages
    When doing chart audits you may chose which exam guidelines you will use- 95 vs. 97, my question is- can you chose per chart which you want to use, or must you utilize that same guideline for every chart for that provider of service throughout that particular audit? Also, can you reference your source please? thanks!

  2. #2
    Location
    Concord, NC or Rochester, NY
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    154
    Default
    You have the choice per chart. In other words you could see patient 1 on day 1 and use 95 and then see patient 1 on day 15 and use 97.

    Just make sure you inform the auditor of the methodology for each chart.

    Hopefully you have a good reason to move between the two types of DGs as this could be confusing internally.

  3. #3
    Location
    Ellenville, New York
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    1,176
    Default While not a written source...
    and I have been searching, but I have heard Dr. Jensen state during his lessons and case of the week on E/M University that when reviewing the exam, both the 95 and 97 guidelines should be reviewed and the one with the results most beneficial to the physician should be used.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  4. #4
    Location
    Ellenville, New York
    Posts
    1,176
    Default We have switched between them
    Quote Originally Posted by mdoyle53 View Post
    You have the choice per chart. In other words you could see patient 1 on day 1 and use 95 and then see patient 1 on day 15 and use 97.

    Just make sure you inform the auditor of the methodology for each chart.

    Hopefully you have a good reason to move between the two types of DGs as this could be confusing internally.
    I just had a review where this happened - on the first record with the patient I review, I used 95 and in the second one (2 month F/U) I used 97 because unlike the first time, the physician documented 3 chronic conditions in the HPI. Since I used 97 for the history with this new informaiton, I stayed consistent and used 97 throughout the chart.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  5. #5
    Default
    In my position as a physician auditor I agree with Dr. Jensen's approach. I use whichever is advantageous to the provider for that encounter. The important thing to remember is to stay consistent within the encounter.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  6. #6
    Location
    Spring Hill
    Posts
    65
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    Quote Originally Posted by missy874 View Post
    In my position as a physician auditor I agree with Dr. Jensen's approach. I use whichever is advantageous to the provider for that encounter. The important thing to remember is to stay consistent within the encounter.
    I audit medical charts and the company uses both 95-97 guidelines. So when we audit we audit using both and we use the outcome that better for the provider.

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