Physician

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Respiratory Examination System/Body Area Constitutional Elements of Examination Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) Head and Face Eyes Ears, Nose, Mouth and Throat Neck Respiratory Cardiovascular Inspection of nasal mucosa, septum and turbinates Inspection of teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palate, tongue, tonsils and posterior pharynx) Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) Examination of jugular veins (eg, distention, a, v or cannon a waves) Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (pulses, temperature, edema, tenderness) Chest (Breasts) 39 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 153
System/Body Area Gastrointestinal (Abdomen) Elements of Examination Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Genitourinary Lymphatic Musculoskeletal Extremities Skin Neurological/ Psychiatric Palpation of lymph nodes in neck, axillae, groin and/or other location Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements Examination of gait and station Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes) Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) 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 Perform and Document: One to five elements identified by a bullet. At least six elements identified by a bullet. At least twelve elements identified by a bullet. Comprehensive 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. 40 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 154
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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
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ACRONYMS AA ABN AEP AIC ALJ ASC CAH
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HIC HIPAA HPSA ICD-9-CM ICD-10-CM/P
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RRB RVU SA SEP SGR SHIP SLP SNF SSA
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Electronic Billing & EDI Transactio
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National Provider Identifier Standa
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United Mine Workers of America Elec
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1995 DOCUMENTATION GUIDELINES FOR E
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II. DOCUMENTATION OF E/M SERVICES T
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Page 111 and 112: occasion the physician who ordered
Page 113 and 114: Table of Risk Level of Risk Present
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Page 123 and 124: REVIEW OF SYSTEMS (ROS) A ROS is an
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Page 131 and 132: System/Body Area Musculoskeletal Ex
Page 133 and 134: Cardiovascular Examination System/B
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Page 137 and 138: Content and Documentation Requireme
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Page 149 and 150: Neurological Examination System/Bod
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Page 159 and 160: NUMBER OF DIAGNOSES OR MANAGEMENT O
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Page 163: D. DOCUMENTATION OF AN ENCOUNTER DO
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Physician

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