Wiki Need help regarding comp exam, PLEASE

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Cyndi113

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Hello all:

Our practice recently (last two months) has converted to EMR. With our conversion, I have been attempting to get my providers to stop documenting a comp exam for ALL patients. For example, patient arrives for test results for HTN, f/u visit for stress test, etc. Not all of my providers document a comp exam but a few are diehards and its easy to do now.

I have taken my concerns to my practice manager and received a request for documentation regarding exam levels. I have read and re-read 1995 and 1997 guidelines and have copies to present. However, does anyone have anything more specific to exam levels? I also have a copy of the CPT nature of presenting problems but it does not specifically state what I need.

Please help!
Thanks in advance,
 
http://www.cms.hhs.gov/apps/apn2/additional51.asp

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a Current Procedural Terminology (CPT) code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."


Hope this helps

Laura, CPC, CEMC
 
I'm in full agreement. Medical necessity is the overriding factor.

A stubbed toe on a healthy patient wouldn't warrant a comprehensive exam. However, a stubbed toe on a patient with circulations or diabetic issues may warrant such an exam.

The documentation of the condition and unlying concerns is just as important as the details of the visit itself.

Suzan
 
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