ENMT System

Can a physician write "exterior ears normal" and receive credit for the entire ENMT system? No other documentation indicating nose, mouth, or throat was examined. Is there any formal guidance out there on this that anyone can possibly share?

Thank You

ENMT exam

That limited documentation does not justify an "entire" or comprehensive exam. The external ears is just one small component of an ear, nose, mouth and throat exam. Look at the 1997 E&M guidelines for what CMS considers to be a comprehensive ENT exam.


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Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Inc.
www.karenzupko.com

ENMT exam

Are you trying to credit the ENMT exam using the 1995 guidelines? There is no formal guidance for scoring exam components that says what the physician needs to document to get credit, unlike the 1997 guidelines. That's why we auditors liked auditing with them better: it was clear, and not subject to our judgment.

Having said that, use whatever set is more beneficial for the provider, and I use the 1995 for high level visits (8 organ systems = a comprehensive exam) whenever possible.

External ears normal seems a stretch to credit ENMT for the 1995. You won't find it in writing, but it makes sense that the physician would have to look in the ears or mouth or throat to get credit for it.

ENMT exam

Agree with Betsy but would say the physician would have to look at ears AND nose AND mouth AND throat (not "or").

Visit www.karenzupko.com for more information on national coding courses sponsored by AANS (neurosurgery/spine), AAOHNS (ent), ACS (surgery), ASPS (plastic surgery), SVS (vascular surgery), AAOS (orthopaedic surgery) and presented by KarenZupko & Associates,Inc.

Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Inc.
www.karenzupko.com

Thank You

Thanks everyone.

These guys use the 95 guidelines (they are pain management). I feel in the absence of formal guidance that if they are trying to get credit for ENMT they should examine ENMT.

Nicole

I hate bullets

but don't you need 2 bullets in the ENMT system to get credit? The external ear includes the visible ear and the external auditory canal (which does require an otoscope to examine) so you could argue that the "external ear" is examination of ear -the visible part -bullet 1 and otoscopic exam of ear canals - bullet 2. I don't see anywhere that you need to examine NM or T to get credit.