First, for a comprehensive exam, body areas do NOT count, only organ systems. While the 95 guidelines do not specifically state how many organ systems must be evaluated for a comprehensive exam, conventional wisdom states that it is eight (8).
The organ systems are:
• Constitutional (e.g., vital signs, general appearance)
• Ears, nose, mouth and throat
It does not appear that the doucmentation supports a comprehensive examination. Since there is no detailed exam of an affected area/organ system, this looks like it would be an expanded problem focused exam at most. Each organization should have a documented policy and procedure to include how the the levels of the 95 guidelines interpret each level and what is required in the documentation of the clinical records to achieve each level.
Secondly, the documentation should reflect exactly what was examined and found to be normal. This is recommended not only for coding but also from a clinical quality perspective. Say the patient has complications from a heart mumur, we have no documentation to show if the heart mumur was present or that the heart was asculatated on this visit.
Feel free to contact me if you have any further questions.
Helen L. Avery, CPC, CHC
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