Wiki Help !!!!!! Unacceptable term in Physical examination- "Uninvolved"

[NishaJ]

Hi .....
Here is an example of PHYSICAL EXAMINATION :Face open and closed comedone, scarring noted, atrophy noted, PIH noted. Forehead Open and closed comedones, scarring, atrophy, PIH noted. Neck Uninvolved. Chest uninvolved. Back uninvolved. Condition status moderate improvement noted.
Here our provider simply mentioned the Neck , chest and Back as "Uninvolved". I have a doubt, how to intreprete this word"uninvolved" , whether the provider has examined and condition not involved in this part , OR the examination even not performed in this part...

I need an assistance on this,whether the credit points will goes on these uninvolved sites also ...

 

[mitchellde]

I would interpret this as an unexamined area or body part. But I would also consult with the provider to verify my interpretation of his/her documentation. If the provider did examine these areas then the documentation of uninvolved is not enough for it to be counted for the visit level. Either way you look at it there is not enough information by the use of the word uninvolved to be considered an examination of the area in question.

 

[NishaJ]

Thanks for your immediate reply mitchell

 

[johnpiaskowski]

query the physician

I would query the physician and ask him to further clarify his meaning of "uninvolved". a physician query can be used as legal record and used as a point of reference in a UM review on that particular case.

 

[NishaJ]

Thank you john, we will query the physician to make sure whether they have performed ....