Coding Growth Strategies

Last week we discussed at length the requirements for the Detailed (99214) Physical Exam. I appreciate all your comments and questions that you've sent in. Today I'd like to continue the discussion about some other tips and tricks I've learned for helping your exam documentation.

Physical Exam Tips

First off, remember these caveats that are a part of the Medicare/Medicaid Coding Guidelines:

• DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient.
• DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described.
• DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

That means that if you want credit for organ systems to count toward your 2 that are required for a Detailed Physical Exam, you have to put more than "normal" or "negative". So let's talk about some specific systems:

Constitutional System:

I feel it is important to address this because this is an often-overlooked system. This can very often be the 'symptomatic or related system(s)' that back up the exam of our 'affected system.' Anytime you have acute illness with fever, for example, we have to remember that fever is part of the constitutional system. Anytime we address a psychiatric issue (anxiety, depression, ADHD) often things like weight gain or weight loss are common side effects that end up being in our HPI. The blood pressure is here to back up the Cardiovascular Exam for patients with hypertension or other types of heart disease.

There are 2 'bullet areas' for this system. The first is to have at least 3 sets of vitals. This is pretty self-explanatory and most of us do this on most patients. The second item is listed as "General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)". You don't have to comment on all of these things; just one.

We want to get out of the habit of putting something like "Constitutional: Normal." Here is my suggestion. First, always put Vitals as a part of the constitutional exam. Auditors know this is a part, but by putting it their it makes us conscious of it. Second, we need to put enough information so that if we want credit for it as a symptomatic or related system, then there will be no question about it.

I'm not going to tell you specifically what to do in your practice. But here are several suggestions for 'Complete' constitutional exams:

• Well-developed, well-nourished.
• General appearance normal.
• Obese
• Overweight
• Underweight
• Very thin/wasted appearing
• Abnormal facies
• Down's syndrome facies
• irty, unkempt
• Well groomed

As you can see, it is very simple to comment on a patient's general appearance. You've really done this simple exam on 100% of all patients. You might as well document it and get credit for it.

Eyes:

Many times we don't do fundoscopic exams on our patients. If you do, then make sure you get credit for it. There are 3 bullet points for eyes:

• Inspection of conjunctivae and lids
• Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)
• Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)

Do notice, however, that we can get credit for 2 bullets without looking at the back of their eyes. Most of the time in pediatrics my exam says "Eyes: Normal". You know I'm a big fan of the 'normal' exam. However, I'm starting to start documenting like this now: "Eyes: Normal conjunctivae and lids." It just takes a simple reset of the button in my EMR for normal eye exam. It is also short enough that I can't really be accused of the sin of copying/pasting my previous exam.

Sometimes I will actually do an exam of pupils and irises. Not very often, mind you; usually it is in the context of a patient with headaches or head injury or something similar. But when I do, I have this simple exam: "Eyes: Normal conjunctivae and lids. PERRLA."

One other point here: It is tempting since we have computers now to actually spell out "Pupils equal, round, and reactive to light and accommodation." In my opinion it is better to leave it abbreviated in this case. First off, this is a well-known abbreviation and there can really be no misunderstanding about its usage. Second, when we write it all out, we have to take the extra time to read it later and it does sort of add to the clutter of the medical record. Plus you get just as much coding credit if you use the abbreviation. So don't be afraid to keep it short!

That's all for now. Over the next several newsletters I'll keep giving you more of my tips about physical exam.

Pediatric Coding Growth Strategies Coming Soon!

For several years now, I've had lots of ideas for a Coding talk specific to Pediatrics. I am currently getting it planned and will let you know more in the next few weeks. Here are some of the topics:

• Newborns: normal vs. not-so-normal and why it pays to chart the difference.
• Pediatric and Neonatal ICU codes: It's not just for Intensivists!
• Pay attention to your ADHD coding: Know when it is 99213, 99214, or 99215.
• Get paid for autism and developmental screening.
• Immunizations: Money-maker or headache?
• The pre-verbal kiddo: 2 points for data review!
• Dental and sports physicals: Easy money, easy coding.
• Health Maintenance Visits and Sick Visits on the same day.
• Siblings Rivalry: Why you should also look at little brother Johnny while he's there.
• The Summer Slow Season: Proven Systems to fill your schedule.
• Your friend Medicaid: You're going to be together for a while; learn to get along!
• Systems, Handouts, and Nursing: Get paid for implementing meaningful use now.
• Specific RVU values and what pays better.

If any of you have other topics specific to Pediatrics that you would like to see addressed, please let me know as soon as possible. I'm hoping to finish this up in the next few weeks then will let you know our plans. Thanks ahead of time for your input.