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Is this an acceptable Physical Exam

  1. Default Is this an acceptable Physical Exam
    Medical Coding Books
    I am auditing a note (established patient) where the physician has documented for a 1/29 visit that the physical exam was performed 1/3....and then proceeds to give a nicely detailed physical exam.

    Is this acceptable or does it rate no credit? I've never come across this before. My instinct was to give no credit but since it's an established patient, there's the added issue of needing only 2 of 3 elements anyway.

    Insight (and links to references) is appreciated

    Tracy

  2. Default
    Bumping in hopes of a response....

  3. #3
    Location
    Salt Lake City
    Posts
    841
    Default
    I am confused so you are saying he did not do a history or medical decision making?
    Jenifer McPolin CPC, CPMA, RCC

  4. #4
    Location
    Ellenville, New York
    Posts
    1,176
    Default No
    I base it strictly on what was performed and documented for the particular encounter - no exam given on 1/29, I will not count an exam for that visit - the one on 1/3 is used for the 1/3 visit not 1/29. Use the history and MDM for your e/m code.

    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. Default
    I'm just getting back here to check the thread....it's been crazy busy at the office!

    jmcpolin - The note has an HPI and MDM. I'm only questioning whether the Physical Exam can be counted when the physician notes that it was performed several days prior. I've never seen this before and my initial search for information didn't turn up anything about acceptable timeliness for a physical exam. (Hope that makes sense!)

    MNTwins29 - My first reaction was to give no credit for the Exam. Then I thought I might be too hasty and that I should research it first. Thanks for the input!

    Tracy

  6. #6
    Location
    Salt Lake City
    Posts
    841
    Default
    Ok now I understand if the exam was not performed on the dos 1/29 you can't use a prior exam.
    Jenifer McPolin CPC, CPMA, RCC

  7. Default
    Thanks! Sorry for the confusion.

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