Ob-Gyn Coding Alert
Get the 95 Guidelines Exam Portion Straight
Question: I have a old audit sheet that states for 1995 guidelines: Problem focused exam: 1-5 elements Is this still correct? Arizona Subscriber Answer: No, these are the guidelines for the 1997 E/M exam documentation. The 1995 guidelines listed only body areas and organ systems, not elements. If using 1995 the exam would be judged as follows: Problem Focused: Limited exam of one body area or organ system. Expanded Problem Focused: Limited exam of the affected body area or organ system plus any other symptomatic or related organ system(s) - commonly interpreted by CMS auditors to mean 2-4 systems total. Detailed: Extended exam of the affected body area(s) and other symptomatic or related organ system(s) - commonly interpreted by HCFA auditors to mean 5-7 systems total. Comprehensive General Multisystem: Documentation of 8 or more findings about the 12 organ systems or a Single Organ System: Not formally defined and left up to the discretion of the auditor, but CMS-defined as a complete exam of a single organ system.
Expanded: 6--11 elements
Detailed exam: 12+ elements
Comprehensive exam: 2 elements in 9 systems
Related Articles
Ob-Gyn Coding Alert
- Hysterectomy, Part 3:
2 Hysterectomy Op Notes Demonstrate What Documentation Makes the Grade — And What Doesn't
Missing language means you won't know what to code. In the previous two hysterectomy articles, [...] - Obstetrics:
Chronicle Complication Visits For Additional Pay Outside Global Package
Complications can occur both prior to the delivery and afterward. So you know you can [...] - Billing:
3 Tips Will Harmonize Your Billing Firm With Your Ob-Gyn Practice
Billers, practices must work together to ensure smooth claims processes. Busy ob-gyn practices that are [...] - You Be the Coder:
Open Ovarian Drilling
Question: Our patient was scheduled for a laparoscopic right oophorectomy along with left ovarian drilling. [...] - Reader Question:
Identify Modifiers in This IUD Removal/Insertion Scenario
Question: My physician removed an IUD hysteroscopically and reinserted a new device while in the [...] - Reader Question:
Here's How to Code Bladder Repair With Milk Infusion
Question: One of our doctors was consulted at the end of a c-section on a [...] - Reader Question:
Tackle This Vaginal Delivery With Uterine Inversion Scenario
Question: I have a patient that had a uterine inversion after a vaginal delivery. The [...] - Reader Question:
Get the 95 Guidelines Exam Portion Straight
Question: I have a old audit sheet that states for 1995 guidelines: Problem focused exam: [...] - Reader Question:
No Easy Solution to Open Paratubal Cystectomy With Myomectomy
Question: Our physician performed an open abdominal myomectomy and removed 19 fibroids. He also performed [...]
