Let's jump right in and continue with our 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. You have to know them. I know as doctors, you really don't want to. Tough. If you want to take money from the government, then you have to play by their rules. Because if you don't, they will take their ball and go home.
The GI exam consists of 5 bullets according to CMS:
My experience is that the typical GI exam goes something like this:
GI: No masses or tenderness. Liver and spleen normal.
Again, like we talked about before, if you include 2 out of a possible 5 bullets, do not expect your auditor to give you credit for a Detailed Exam. Notice a couple interesting things in the descriptions, however. Point #4 and point #5 both say that the examination of the anus, perineum, rectum, and stool for occult blood are only 'when indicated.'
Many auditors would say that these are not really absolutely required for a Detailed Exam if you can say they are not indicated. Obviously if they are indicated you should've already done this and documented it. But if not, you could make a case for an extended exam of the GI system if you include all of the first three bullets in your exam.
I'm not going to go into a lot of discussion on the GU exam because I feel it is fairly self-explanatory. You know if you've done a detailed exam or not. Basically for males this must include the scrotum, penis, and prostate (although you can definitely get away with not doing this in pediatrics). For females it is the typical pelvic exam. For completeness sake, here are the bullets:
MALE:
FEMALE:
Pelvic examination (with or without specimen collection for smears and cultures), including
Just be sure that whatever kind of template you use, whether EMR or paper or just 'in your head' that you have these specific listed points. These points will make your auditor's job easier. And by extension, your life as well.
Not much to say here. The lymph node locations are Neck, Axillae, Groin, and Other (4 total). Be sure that if you indicated a lymphatic exam, you indicated which nodes were examined.
Usually, to get credit for an extended musculoskeletal exam, this will have to be the affected organ system. Which usually means they are having pain, numbness, swelling, injury, etc. Here are the bullet points:
Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:
Considering that we see most patients either walk into or out of a room, we can easily comment on gait and station. Often the digits and nails can be commented on in the same way. My typical limited musculoskeletal exam would look something like this:
Musculoskeletal: Normal gait/station.
Pretty straightforward, right? Again, this will not get you credit for the affected organ system. But it can get you credit if you want musculoskeletal as part of you 'symptomatic' or 'related' organ system. So what about a negative Detailed musculoskeletal exam. Let's say someone comes in with a simple sprained ankle. I would organize my exam like so:
Musculoskeletal: Gait: Limping, favoring right ankle.
Right ankle exam: Palpation: Mildly tender lateral malleolus.
Range of motion: Normal.
Stability/dislocation: Normal.
Muscle strength/tone: Normal.
As you can see, you can still write a Detailed note and have it be short, sweet, and readable.