Physician

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Eye Examination System/Body Area Elements of Examination Constitutional Head and Face Eyes Test visual acuity (Does not include determination of refractive error) Gross visual field testing by confrontation Test ocular motility including primary gaze alignment Inspection of bulbar and palpebral conjunctivae Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) Ophthalmoscopic examination through dilated pupils (unless contraindicated) of Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages) Ears, Nose, Mouth and Throat Neck Respiratory 23 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 137
System/Body Area Elements of Examination Cardiovascular Chest (Breasts) Gastrointestinal (Abdomen) Genitourinary Lymphatic Musculoskeletal Extremities Skin Neurological/ Psychiatric Brief assessment of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation) Content and Documentation Requirements Level of Exam Problem Focused Expanded Problem Focused Detailed Comprehensive Perform and Document: One to five elements identified by a bullet. At least six elements identified by a bullet. At least nine elements identified by a bullet. Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border. 24 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 138
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Medicare Physician Guide A Resource
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ICD-9-CM Notice The International C
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MEDICARE PHYSICIAN FEE SCHEDULE ...
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CHAPTER ONE INTRODUCTION TO THE MED
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THE MEDICARE PROGRAM The Medicare P
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worker must have a specified number
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Part B - Medical Insurance Some of
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Where to Find Additional Informatio
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CMS contracts with one Quality Impr
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This chapter discusses Medicare pro
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staff or faculty appointments, part
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The following forms are often requi
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Accept the Medicare allowed amount
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Below is an illustration of the pay
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cultural background, or ability to
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This chapter provides information a
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suppliers can obtain a list of elec
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Insurer information (name, group nu
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Coordination of Benefits Contractor
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In these situations, the physician
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Where to Find Additional Informatio
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OTHER HEALTH INSURANCE PLANS Medica
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Part B Railroad Retirement Benefits
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This chapter discusses Medicare cov
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2) Renal dialysis treatments Renal
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2) Furnished by the physician or au
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Services that are considered not me
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This chapter discusses common sets
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International Classification of Dis
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CHAPTER SIX PROTECTING THE MEDICARE
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codes that describe what is and is
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Consistently using billing or reven
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Investigations A Program Safeguard
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Sanctioned and Reinstated Provider
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CHAPTER SEVEN INQUIRIES, OVERPAYMEN
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If Medicare pays more than the corr
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It contains the name, telephone num
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filed), the time limit will be exte
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Liability and Appeal Decisions Liab
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REFERENCE SECTION Medicare Physicia
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Coinsurance Under the Original Medi
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Medically Necessary Services or sup
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Participating Provider or Supplier
Page 87 and 88: ACRONYMS AA ABN AEP AIC ALJ ASC CAH
Page 89 and 90: HIC HIPAA HPSA ICD-9-CM ICD-10-CM/P
Page 91 and 92: RRB RVU SA SEP SGR SHIP SLP SNF SSA
Page 93 and 94: Electronic Billing & EDI Transactio
Page 95 and 96: National Provider Identifier Standa
Page 97 and 98: United Mine Workers of America Elec
Page 99 and 100: 1995 DOCUMENTATION GUIDELINES FOR E
Page 101 and 102: II. DOCUMENTATION OF E/M SERVICES T
Page 103 and 104: DG: The CC, ROS and PFSH may be lis
Page 105 and 106: For purposes of ROS, the following
Page 107 and 108: DG: At least one specific item from
Page 109 and 110: C. DOCUMENTATION OF THE COMPLEXITY
Page 111 and 112: occasion the physician who ordered
Page 113 and 114: Table of Risk Level of Risk Present
Page 115 and 116: 1997 DOCUMENTATION GUIDELINES FOR E
Page 117 and 118: I. INTRODUCTION WHAT IS DOCUMENTATI
Page 119 and 120: III. DOCUMENTATION OF E/M SERVICES
Page 121 and 122: DG: The CC, ROS and PFSH may be lis
Page 123 and 124: REVIEW OF SYSTEMS (ROS) A ROS is an
Page 125 and 126: DG: At least one specific item from
Page 127 and 128: Problem Focused Examination - shoul
Page 129 and 130: System/Body Area Respiratory Elemen
Page 131 and 132: System/Body Area Musculoskeletal Ex
Page 133 and 134: Cardiovascular Examination System/B
Page 135 and 136: Ear, Nose and Throat Examination Sy
Page 137: Content and Documentation Requireme
Page 141 and 142: System/Body Area Elements of Examin
Page 143 and 144: Content and Documentation Requireme
Page 145 and 146: System/Body Area Elements of Examin
Page 147 and 148: System/Body Area Musculoskeletal Ex
Page 149 and 150: Neurological Examination System/Bod
Page 151 and 152: Content and Documentation Requireme
Page 153 and 154: System/Body Area Psychiatric Elemen
Page 155 and 156: System/Body Area Gastrointestinal (
Page 157 and 158: System/Body Area Skin Elements of E
Page 159 and 160: NUMBER OF DIAGNOSES OR MANAGEMENT O
Page 161 and 162: RISK OF SIGNIFICANT COMPLICATIONS,
Page 163: D. DOCUMENTATION OF AN ENCOUNTER DO
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Physician

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