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Weekly Tip-Scoring of Exam

Posted: Fri Jan 30, 2015 9:11 am
by lori
Hi. I was kinda surprised that this Exam only scored as EPF. Can you tell me how you assess whether an exam of a particular organ system is 'detailed' or not? For instance, what was the rationale behind not allowing the cardio exam (normal rate, rhythm, and sound) as 'detailed'? Thank you!

Re: Weekly Tip-Scoring of Exam

Posted: Tue Feb 03, 2015 11:26 am
by Shannon DeConda
Lori-
Great question! This is an area that is not truly defined by 1995 Documentation Guidelines. Some carriers have posted some guidance on the matter, and most would agree that "in detail" would be 3-4 exam findings of that organ system. These exam findings would correlate to the exam findings represented by each bullet under that specific organ system in 1997 Guidelines.
So using the example and your question about the cardio- all three of those findings related to Auscultation of heart with notation of abnormal sounds and murmurs and therefore it would not reach what we would define as a "detailed" exam.
I'm glad you posted this question as that finding was created to make auditors think about and access the exam more thoroughly.

Re: Weekly Tip-Scoring of Exam

Posted: Wed Feb 04, 2015 9:50 am
by lori
Thank you a bunch for taking the time to explain that for me. Have a great day!