March 16, 2017

Question:
I have a question after a recent coding/billing seminar with Teri Romano (which was excellent!). I use the 1997 Physical Exam Rules and am trying to figure out the required elements for a comprehensive exam. Most information says you need 2 bullets from each of 9 organ systems. While this is easy to understand, I noticed the guidelines also says:

Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least 2 elements identified by a bullet from each of nine areas/systems.

I don’t understand the part underlined above. Can you please explain this? Thank you.

Answer:
There are 15 organ systems or body areas listed in the 1997 Exam (pages 82-83); eye, neck, respiratory, cardiovascular, etc. You need to document at least 2 in nine of the system/body areas. Technically, the rule states that you must perform (exam) all but you only need to document 2. You will document the two in each system that you examined for a medically necessary reason. In the event of an internal or external audit, the reviewer will “count’ the number of elements you documented. A comprehensive exam is justified if you document 2 in at least 9 system/body areas (18 total).

If your exam typically addresses organ systems, for example, cardiovascular, skin, respiratory, musculoskeletal, etc., you would do better to use the 1995 Exam. If you document that you examined at least one element in each of eight organ systems, it justifies a comprehensive exam.

*This response is based on the best information available as of 03/16/17.