The best 99214

Hey everyone, today I'm continuing with part 3 of our series on writing the best 99214 note that you can. So what is a great 99214 note? From our first newsletter, I define it as:

  1. Do only the amount of History and Physical Exam that you think is necessary and important for that particular patient.
  2. Write the note and consciously put in all the requirements of a 99214 note.
  3. Go over and above and satisfy all 3 things of History, Exam, and Decision Making (not just 2/3).

Last week we wrapped up our discussion on History. Today we're going to talk about Physical Exam.

Physical Exam

A 99214 requires a Detailed Physical Exam. According to 1995 guidelines, this is an 'extended exam of the affected organ system plus other related organ systems.' This is fairly vague but I think most of us know what that means. If you listen to the heart or lungs and the auscultation is normal, that does not make it a 'detailed exam'. The 1997 guidelines state that you need at least 2 bullet points from at least 6 systems or 12 bullet points total. While I'm not a fan of bullets, sometimes this can be helpful when it comes to designing templates.

I don't know what your ideas are about templates. But whether you admit it or not, we all use templates. For some of us, that means paper or electronic items that will either check off boxes or fill in the blanks. For the rest of us, that means a pattern in our head where we put things like "clear to auscultation bilaterally." But we all use templates.

What I like to do is create templates based on what I consider a detailed physical exam. I've got detailed physical exams for several types of patients. Here are a couple templates I use frequently. The first one is a normal detailed exam I use for most viral/URI/sick visits:

Constitutional: Normal appearing. Eyes: Normal lids and conjunctivae. ENT: Auditory Canals: Normal bilaterally.

Tympanic Membranes: Normal bilaterally. Ears: Normal bilaterally. Lips, Teeth, Gums: Normal. Oropharynx: Normal. Pharyngeal Walls: Normal. Neck: Normal.
Cardiovascular: Auscultation: Regular rate and rhythm. No murmur. Respiratory: Chest: Normal appearing.
Respiratory Effort: Normal. Auscultation: Clear bilaterally.
Gastrointestinal: Abdomen: Soft, nontender.
Liver: No hepatomegaly. Spleen: Normal.

Here is a physical exam I use for a normal psychiatric follow-up (ADHD, anxiety, depression, etc.):

Constitutional: Normal appearing. Cardiovascular: Auscultation: Regular rate and rhythm. No murmur. Respiratory: Respiratory Effort: Normal.

Auscultation: Clear bilaterally.
Psychiatric: Speech: Normal.
Thought Processes: Normal. Abnormal Thoughts: None. Judgment: Normal. Orientation: Oriented to time, place, and person. Recent Memory: Normal. Attention Span: Normal. Language: Normal. Mood: Normal.

One key to remember is you cannot use the descriptor 'normal' when referring to the affected or related organ systems in a detailed exam. You can, however, break down the organ system into its component parts and each individual part you can list the pertinent positives/negatives or put normal. At the end of this newsletter, I've included the component parts for the organ systems as defined by CMS in the 1997 guidelines. Use these parts to design your templates and it will save you a ton of time and effort.

And don't forget: you are to do the amount of exam that is necessary to take care of the patient. Then read through the template and document everything you did. If you did not do enough for a detailed exam, then that is fine! You may have only done enough work for a 99213. But remember, you never want to have a template that you fill out 'just because' you want to create a 99214. Never do extra work just to satisfy guidelines. Either it was necessary to do the work or it wasn't. This is how you stay out of any kind of fraud.