Eli's Rehab Report

Question: If a physiatrist is using a single system exam to record information from the patients physical during an evaluation and management, but records a statement on the patient chart, Lungs clear, does the doctor get credit for that bullet?

New York Subscriber

Answer: The answer to this question doesnt involve a single system versus multisystem exam as much as it involves the difference between HCFAs 1995 documentation guidelines and the 1997 guidelines.

HCFAs 1997 evaluation and management (E/M) guidelines are very clear about documenting each area of an exam. These guidelines state, for example, that the physician should make a note regarding breath sounds, adventitious sounds and/or rubs heard during the auscultation of the lungs. The 1995 guidelines, however, dont provide this detail, and lungs clear would be acceptable documentation for an exam of the respiratory system.

Both the 1995 and 1997 Guidelines for Documentation of Evaluation and Management Services can be downloaded from the Internet at the Web site www.hcfa.gov/medicare/mcarpti.htm.