R. Arthur N. Lurvey, M.D.
Dear Dr. Lurvey,
I have been studying the E&M guidelines for my specialty for 3 hours so far today. Here are my questions regarding a comprehensive physical examination:
1. Do I still get credit for documenting a required element if the patient refuses this part of the exam or is uncooperative for this type of exam as long as I document that this is the case?
2. I am supposed to document at least one element in each unshaded box, but for some organ systems, no elements are identified: i.e. Genitourinary, Musculoskeletal. What do I do here?
3. Can I get credit if I perform and document more elements in one unshaded box as substitution for documenting fewer required elements in another unshaded box, if it is more clinically relevant for a given patient?
4. If there is already a specialist examining the patient in another organ system, say cardiology, can I defer to this specialist's expertise as long as I agree with their exam and document that I agree?
5. I realize after all my study, that previously, I have performed enough elements to qualify for a comprehensive exam, but have not documented to this level since it is so irrelevant to do so. This type of documentation also clutters up the medical record. Therefore, I was actually undercoding. When I typed up my comprehensive hospital note it came out to be 6-12 pages long depending on the patient. Should I include a Table of Contents?
I have enclosed copies of my other 4 letters to which you have not yet responded so that you can respond more easily, all at once. I there is a specific person at HCFA that you recommend, please let me know and I will address my many questions and problems with Medicare to them.
Linda Wilson, M.D.
CC. Jane Orient AAPS