Vaida Posted Tue 09th of April, 2013 14:16:31 PM
We are using 1997 physical exam guidelines. If a provider examines one area only of the grouped areas, does he get a proper credit for it. For instance, there are grouped areas in the Skin Exam:
Genitalia, groin, buttocks;
Chest, including breasts and axillae;
Head, including the face
So if he examines a face only and not the scalp, does he get credit, or he must examine the whole head?
SuperCoder Answered Wed 10th of April, 2013 08:42:26 AM
Under 1997 PE guidelines, there are 2 bullet points that can be collected by a physician at max.
1) Inspection of skin & subQ tissue (rashes, lesions, ulcers)
2) Palpation of skin & subQ tissue (induration, subQ nodules, tightening)
There is no "min. no. of skin locations" mentioned inthe guidelines. So any of the skin area checked/examined is capable of bringing in points. It's not necessary to check multiple locations. Even if multiple groups are "inspected", you still get 1 bullet.