Today we will conclude our 4-part series on Physical Exam tips and tricks. Again, remember, our discussion is what separates the limited exam (99213) from the extended exam (99214). Going back to our definition from 1995/1997 guidelines, a Detailed Exam must have an 'extended exam of the affected body area or organ system.' That means if we want credit for a 99214 exam, whatever the 'affected' organ system is must have lots of details. You can still use words, like normal or negative, but you have to include to specific parts of the exam that you are dealing with. If you say something like "Respiratory: Normal" you better not expect your auditor to give you credit for a detailed exam.
For reference, I am referring to the 1995 Coding Guidelines (pages 8-10) and the 1997 Coding Guidelines (pages 10-42). Make sure you bookmark or download these guidelines.
Even though we are not dermatologists, we often do a limited skin exam. Many of us will do detailed skin exams from time-to-time as well. Let's look at the bullet requirements:
So it comes down to how do you want to document? If you want credit for both aspects, the simplest line for a negative exam is "Skin: Normal to inspection and palpation." We have not been discussing the 'comprehensive' physical exam so far, but if you look down into page 43 of the 1997 guidelines, we see this description:
NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements.
I think the takeaway message here is that if you do a more extensive skin exam, even if it is negative, you need to list each of the systems that you exam separately (Abdomen, Chest, Back, etc.).
If you do a comprehensive neurologic exam, you need to indicate everything that you learned to do in medical school for a neurologic exam. Refer to the 1997 guidelines for information. However, for the relatively straight-forward exam, here are the bullet points:
Neurologic is one system that I would hesitate from saying on physical exam "Neuro: Normal" because that is one area that your auditor is going to probably ask what you meant. Did you mean cranial nerves or reflexes or sensation was normal? If you do any of these, be sure you document them specifically.
Brief psychiatric exams can be done fairly regularly. In fact, many parts of this exam are done just by having a conversation with the patient. Here are the bullet points:
Brief assessment of mental status including:
This is worthwhile to have a normal template that you can pull out when dealing with your depressed, anxious, or other psychiatric patients. Here's a quick one:
Psychiatric: Judgment/insight: Normal.
Orientation: oriented x 3.
Memory: Normal.
Mood/Affect: Neutral.
Again, often even for simple exams when they come in to be seen for strep throat, we have done 2-3 of these bullet points. If you've done the work, be sure you get credit for it!