Wiki Physical Exam - I am performing an audit

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krssy70

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I am performing an audit, and on my audit tool, it lists Body Areas and Organ systems. Can I count the total of both. So for example, I have 4 body areas: Head, Chest (breasts), Abdomen, and extremity... Then for my organ systems I have: Constitutional, card, resp, and lymph... Can I count that as 8 systems?

Thanks,
 
1995 guidelines

For a comprehensive exam, following the 1995 guidelines, the physician must document examination of 8 organ systems. Body area do NOT count for the comprehensive exam at all.

For EPF - Limited exam of the affected body area or organ system, plus other related or symptomatic organ systems.

For DETAILED - Expanded exam of the affected body area or organ system, plus other related or symptomatic organ systems.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
We have been instructed by Highmark Medicare Services, our MAC, that you cannot combine body areas and sytems for any level. It is one, or the other. However, depending on what you have for documentation for the body areas, they can also apply to the organ systems - i.e. Abdomen = GI, Chest (breasts) = Integumentary, Extremities = Muscular Skeletal or cardio, Head = Eyes, Ears, Nose, Mouth, Neck = Lymph etc., - so if your documentation would support this, then you would have 8 systems.
 
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