I would like to continue this week with my Physical Exam Coding Tips. We started last week by talking about some issues when it comes to the Constitutional and Eye systems. Let's keep that theme rolling.
In pediatrics, the ENT exam is very often one of the exam systems that I go into detail on. If we think about when we see patients with acute problems, they often fall into the upper respiratory, sneezy, itchy, coughy, congested, runny, sore throat realm, right? So get in the habit of having an ENT template that you can pull out of your pocket.
According to CMS guidelines, there are 6 bullet points for the ENT exam:
Most of us in primary care do not do the hearing or the nasal exam. However, it is very common for us to do the other 4 bullets. Whether you are going by 1995 or 1997 guidelines, you need to make sure you document whenever you do this more detailed kind of exam. Many of you have seen my ENT exam template before, but let me show it to you again. The key is having all the right things in the details; you can still use the work 'normal', but you need to indicate to your auditor what part of the system you were examining. And I think it is wise to group it into the 'bullet systems' like so:
Ear, Nose, Mouth, Throat:
External ears/nose: Normal.
Auditory canals/Tympanic Membranes: Normal bilaterally.
Lips/teeth/gums: Normal.
Oropharynx: Normal.
When we put in this exam, it is still very quick and easy to write. And still very quick and easy to read if you are looking over old notes or someone else's notes. But it will make sure you get credit for all the work you did. If you use an EMR template, it is easy to get this to show up on your note. But for those that still use paper, it is very easy to make sure you have a semi-detailed template like above instead of just having "ENT: normal." Unless, of course, you just did a small "limited" exam or if ENT was not an 'affected' or 'symptomatic' or 'related' organ system.
I'm not going to spend much time on the neck exam. It consists of the following bullets:
You can get credit for 2 bullet points with: "Neck: Trachea midline; no masses. Thyroid normal."
The respiratory system has 4 bullet points. In a typical exam, most of us only do the first and last ones. They are:
So, that means for a typical respiratory exam, it'll probably look something like this if normal:
Respiratory: Normal respiratory effort. Auscultation: Clear bilaterally.
Not very impressive, is it? Another thing to remember is that your auditor may or may not feel like giving you credit for an extended exam of the Respiratory system if you only include 2 out of 4 bullets. What do you think? So let's say someone comes in with asthma and you think you have enough history, exam, and decision-making for a 99214. If you didn't do percussion and palpation of the chest then you may not have done a Detailed Physical Exam. So make sure you have enough history and decision-making to qualify for the 99214 you think you deserve. If you've done the work, then the simple Detailed negative exam would look like so:
Respiratory: Normal respiratory effort.
Percussion of chest: Normal.
Palpation of chest: Negative.
Auscultation: Clear bilaterally.
So my take-away message for Respiratory exam is don't think you've done enough for a 99214 exam if the Respiratory system is the affected organ system unless you've done percussion and palpation also.
Some of the same problems apply to the Cardiovascular system as they do to the respiratory system. Look at the bullets to see what I mean:
A typical 'limited' exam usually consists of auscultation plus maybe edema in extremities. If you include these two things only, there is no way you'll ever convince your auditor that you've done a Detailed exam of that organ system. So if you want credit for an 'extended exam of the affected organ system' and you are dealing with the cardiovascular system, you have to include all the arteries listed above. That is the difference between an Extended Problem Focused and a Detailed Physical Exam.