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aguelfi

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I have a physician who dictates the follow:

An examination of all the Systems/Body Area Elements outlined in the General Multi-System Examination was performed. All elements of the exam were normal except for the following abnormal findings and pertinent negatives:
1. Overweight
2. DRE smaill Hemorrhoids, Fecal immune test negative.
3. Prostate 1-2+, smooth, firm anodular
4. Bradykinesis
5. Mild maksed facies, Broad-based shuffling gait

Would you give credit for a comprehensive exam, and if not can you tell me where the documentation must list each system reviewed individually?
 
Document vs perform

The 1997 audit tool specifically states that for a Comprehensive Exam
"PERFORM ALL elements in at least 9 areas/systems and DOCUMENT at least 2 elements from each of 9 areas/systems. "

If it's not documented it wasn't done.

F Tessa Bartels, CPC, CEMC
 
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What I'm getting at is, is it acceptable to make a comment that the elements were performed and are normal or negative, only listing the abnormal findings....like it's acceptable to do w/ ROS?
 
Comprehensive Exam

If you want credit for a comprehensive exam, you need to document each element that makes up that exam. Just saying "everything normal except ..." does not tell me which elements you actually performed, and, in my opinion, does not constitute documentation of the required elements.

Just my opinion.

F Tessa Bartels, CPC, CEMC
 
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