does this count for physical examination?

I am auditing several charts which billed as a level 5 consult, which for a comprehensive physical examination included only the
the following comments:

1. Patient currently sleeping, hence physical exam deferred at the request of the family.

2. physical exam unchanged from last exam (without stating the specific date of last examination.

3. physical exam: patient undering EEG, sedated and pharmacologicallyy
paralyzed.


Several of these patients were clearly complex, ie. in the ICU with multiple medical problems but with the only exam documented as above, I am write for limiting the
examination to only problem focused??

You are right!

You can still examine a sleeping, paralyzed, unchanged patient and get significant findings. The doc can also document- Neuro- limited due to sedation or gait- unable to be tested, etc to get all the bullet points for a comprehensive exam.
Consults require all three elements- Hx, Px, MDM and these fail the Px. Give 'em a level 1-3- remember you don't make the rules just enforce them, and that is better than CMS knocking on the door in a year asking for the money back.

does this count for physical eamination

1) patient asleep gets no exam credit. The physician should come back later.

2) Unchanged gets no credit. Only the ROS and PFSH can be listed as "Reviewed and unchanged since...."

3) Todd Thomas has this posted on his website about being unable to get an exam. I have never seen that directly from CMS. I would be very careful, and would again say, come back when the EEG is over, and exam: heart, lungs, abdomen, skin, document vitals, neuro, muscle tone, and note you couldn't look in their mouth because the patient was intubated.

http://ercoder.com/discussion/topic.php?id=21

There are a number of articles about the Documentation Guidelines in Codapedia, and they might help you.

http://www.codapedia.com/custom.cfm?name=codaTags.cfm&tag=20