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Thread: Physical Exam question

  1. #1

    Post Physical Exam question

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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

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