Wiki E & M Guidelines question

[foxsd]

Hello, all.

The guideline for a general multi exam says to "perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet for each of nine areas/systems."
My question is this - to receive credit for a bullet, must the provider document the location, size and thrills (or for other systems, what ever is in the parenthesis) before we can give him credit for the palpation of heart? & with the second bullet (*) as long as the provider documents "No murmur", correct?


Cardiovascular:
* Palpation of heart (eg, location, size, thrills)
* Auscultation of heart with notation of abnormal sounds and
murmurs

Thanks in advance!

Sabrina Fox, CPC, CCA

 

[thomas7331]

For each bullet, you're just counting that it was performed and that the relevant findings were documented; it's not necessary for the provider to document everything that is named under the bullet. So for example, the documentation might just state: 'Chest CTA' ('clear to auscultation') which documents that ausculation was performed and there were no abnormal findings, which would be sufficient to count the bullet.

I'd refer you back to section B 'Documentation of Examination' earlier in the guidelines which will give you additional direction on this:

Parenthetical examples “(eg,…)”, have been used for clarification and to provide guidance regarding documentation. Documentation for each element must satisfy any numeric requirements (such as “Measurement of any three of the following seven...”) included in the description of the element. Elements with multiple components but with no specific numeric requirement (such as “Examination of liver and spleen”) require documentation of at least one component. It is possible for a given examination to be expanded beyond what is defined here. When that occurs, findings related to the additional systems and/or areas should be documented.
DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is insufficient.
DG: Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
DG: A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

 

[foxsd]

Thank you for your response.

I’m getting caught up on the wording for the comprehensive exam. It says the physician must “perform ALL” elements identified by “A” bullet in a minimum of 9 organ systems/body areas. So to me that means the physician doesn’t necessarily have to perform every bullet. Just one bullet per body area but all of the elements within that specific bullet have to be “performed”. The kicker however, is that while the wording says ALL elements must be performed, the guidelines only require that you “document” at least two.

What is your take on this?