Results 1 to 3 of 3

Physical Exam question

  1. Post Physical Exam question
    Medical Coding Books
    We have spent most of this year trying to educate our physicians on the proper way to document consults and office visits. They have improved somewhat, but some of them argue this point about the physical exam. Documentation requirements are for a certain number of elements identified by a bullet. Some of our doctors say the elements are just examples, and they can document anything in the body system or body organ. My understanding is that it has to be the specific element listed. Is there anything in writing that clairifies this question?

  2. #2
    If they are using the 1997 exam guidelines, they must examine and document exactly what the bullet says.

    They can certainly examine whatever they want, and if it's not listed on the 1997 DG's, they would need to defer to the 1995 guidelines.

    That's why there are two sets depending on the provider's preference- one specific, one non specific, they can use either or but cannot combine the two for the same patient.

  3. #3
    Milwaukee WI
    Default Check with your carrier
    Something I just learned at a conference last month ...
    some Medicare carriers DO allow you to mix the 1995 and 1997 guidelines in the following way:
    You can use the status of 3 chronic conditions (1997) for HPI
    AND use the 1995 exam guidelines in the same note.

    NOT every state's carrier allows this, but if you are in a state that does allow it ... go for it.

    F Tessa Bartels, CPC, CPC-E/M

Similar Threads

  1. Physical Exam Question
    By LindsayC in forum E/M
    Replies: 2
    Last Post: 04-16-2013, 03:08 PM
  2. Physical Exam Question
    By LindsayC in forum Auditing General Discussion
    Replies: 1
    Last Post: 04-15-2013, 02:05 PM
  3. Physical Exam Coding Question
    By LindsayC in forum E/M
    Replies: 3
    Last Post: 03-08-2013, 10:23 AM
  4. Physical Exam question
    By melzinser in forum Auditing General Discussion
    Replies: 2
    Last Post: 02-14-2011, 01:57 PM
  5. Annual exam vs Physical exam question
    By NIEVESM in forum Family Practice
    Replies: 11
    Last Post: 09-01-2010, 06:59 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.