Wiki Physical Exam Documentation

[MichelleBursavich]

This is a question about documenting the physical exam.

Our Clinical treatment forms are templates that have "check" boxes for ROS, PFSH, Physical Exam Body Areas/Organ Systems. There are also diagrams of the body since we are Dermatology specialty.

When the provider is documenting the physical exam, can he/she just draw a line to the body part on the diagram and write what the finding is without checking the appropriate box for body area/organ system?
OR
does the provider have the check the appropriate box under the physical exam section indicating which body area or organ system was examined?

Any help is appreciated. Thank you.

 

[thomas7331]

The NGS Medicare in the region where I work allows check-list documentation for an expanded problem focused examination, which they describe as 2-5 body areas or systems with "Minimal detail for areas and/or systems examined; check list type documentation without any expansion of documentation of findings". For a detailed exam, they require 6-7 body areas or systems with "Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon." I think this is good pretty guidance that would apply well to most payers and protect you well in an audit, and I would advise providers to avoid relying on checklists for documentation of detailed and/or comprehensive exams, but I'd recommend reviewing your own local payers' E&M policies, if they have ones, so that you're familiar with their expectations.