Wiki 95 exam guidelines

[sharonpurnell]

I work for an orthopedic office and would like input on using 95 guidelines. My concern is for the exam. I have been told 2 different ways to audit with 95 guidelines and I am hoping someone can help. New patient comes in and the Dr. exams all 4 extremities range of motion and stability are good. He also has pedal pulses are good which is Cardio and listens to the breathing and documents. Would this be a total of 6 body areas/organ systems or just 4 body areas. I have been told that you can use body areas/organ systems together and I have been told that you either have to use body areas or organ systems. Please help

 

[hewitt]

It's atcually both. You can use body areas and systems as bullet points for problem focused (1 body area/system), expanded problem focused (2 to 7 body areas or systems), and detailed (2 to 7 body areas or systems). However, you can only use systems for a comprehensive exam (8 or more systems). In your example above, my understanding is this would be 4 body areas (each extremity), Cardio (1 system), and breathing (1 system). So, 4 body areas and two systems or EPF exam. Our Medicare provider allows us to document two bullet points for at least two systems to be counted as a detailed exam. So, if the Cardio and Respiratory have at least two bullet points (look at the 1997 Guidelines for examples of bullet points), I would code this as a detailed exam. There are fewer than 8 systems documented, so it could not be a comprehensive exam. Tried to keep this short and specific to your example. Hope this helps. The exam would be slightly different if you used the 1997 Guidelines.

 

[mitchellde]

The 95 guidelines have the list of the recognized body areas/ systems. Go by that list. If musculoskeletal is listed as one area/ system then no matter it is one area. A detailed exam is an extended review of the affected area/ system plus any other related or symptomatic areas/ system.