Coding Growth Strategies

Hey everybody! I am finishing up preparing for this Summer's Advanced Coding Growth Strategies and have an important topic I would like to discuss. There have been many discussions (and misunderstandings) of the Detailed Physical Exam. In fact, in the past I have been guilty about misunderstanding this as well. So let's dig in.

First off, I want to use as references the 1995 Coding Guidelines (pages 8-10) and the 1997 Coding Guidelines (pages 10-42). As many of you know, I've always been more of a fan of the 1995 guidelines than 1997, because I felt they were simpler and they favored the doctor. That still holds true in my opinion. I want to point out a few of the specifics of the 1995 guidelines first.

A Detailed exam is defined as "an extended examination of the affected body area(s) and other symptomatic or related organ system(s)." This means it must contain at least 2 organ systems: then affected system plus at least one other symptomatic or related organ system. CMS has several points they make in their 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).

So what does this mean for us? It means that on the two systems that you want credit for (the affected or symptomatic systems), you have to document more than "normal" or "negative". The question arises can I put "normal" on a 'related system'. For example, if someone comes in with fever, URI symptoms, and sore throat, I can put detailed information on the ENT exam; but do I need details on the Respiratory system or can I put "normal"? We will discuss this further below with a few examples.

So what about 1997 guidelines? The definition is exactly the same as the 1995 guidelines. The three bullet points mentioned above are exactly the same as well. However it is further elaborated on page 12 where it discusses 'bullets':

• Detailed Examination - should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (*) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (*) in two or more organ systems or body areas.

Basically, you can have 2 bullets in at least 6 organ systems, or a total of 12 bullets in at least 2 systems. While this is much more objective criteria than the 1995 guidelines, your documentation will probably be similar between 1995 and 1997 elements. Let's look at a few examples:

Patient comes in with history of fever and sore throat and I do the following Physical Exam (of course courtesy of SerenityEMR):

Physical Exam:
Vitals: Weight: 135lb Height: 5' 5" BMI: 22.5 Pulse: 92 Resp: 18 Temp: 99.8°F
Constitutional: Normal appearing.
ENT: Auditory Canals: Normal bilaterally.
Tympanic Membranes: Normal bilaterally.
Ears: Normal bilaterally.
Nose: Normal.
Lips, Teeth, Gums: Normal.
Oropharynx: Normal.
Pharyngeal Walls: Bilateral red swollen tonsils.
Neck: Normal.
Cardiovascular: Normal/Negative.
Respiratory: Normal/Negative.
Gastrointestinal: Normal/Negative.
Heme/Lymph/Imm: large anterior cervical lymphadenopathy.

When I look at this note, I quickly think 'detailed physical exam'. Because it looks like I've got an extended exam of the affected organ system (ENT) plus at least one other affected organ system (Lymph). I have also satisfied the requirements that I did not use "normal" or "negative" for the affected or related systems.

If I grade this by 1997 guidelines, how many bullets do I have? First off, many auditors disagree about the organ systems labeled "Normal". Some would give you one bullet for those. But some will not. For example, with cardiovascular, these are the bullets possible:

• Palpation of heart (eg, location, size, thrills)
• Auscultation of heart with notation of abnormal sounds and murmurs
• carotid arteries (eg, pulse amplitude, bruits)
• abdominal aorta (eg, size, bruits)
• femoral arteries (eg, pulse amplitude, bruits)
• pedal pulses (eg, pulse amplitude)
• extremities for edema and/or varicosities

The odds are, if you put "Cardiovascular: Normal" you probably auscultated the heart. Reasonable auditors will give you credit for this. But if you have a 'stickler for the rules' you would actually have to indicate "normal to auscultation" or possibly "regular rate and rhythm without murmur." This is a decision you'll have to make for yourself.

But if the auditor gives you credit for those, then this note in 1997 guidelines would be worth 10 bullets:

• constitutional (3 vitals)
• constitutional (general appearance)
• ENT (external appearance of ears)
• ENT (otoscopic exam of ears)
• ENT (lips, teeth, gums)
• ENT (oropharynx)
• Cardiovascular
• Respiratory
• GI
• Lymph (neck lymph nodes)

According to 1997 guidelines, that is not enough for a Detailed Exam. So, if you have an auditor that is 'out to get you' (and really, aren't they all?), then you do not want to give them any further ammunition. You don't meet criteria for 1997 Detailed Exam. So you must be absolutely sure you meet criteria for the 1995 exam! Let me change our note very simply:

Physical Exam:
Vitals: Weight: 135lb Height: 5' 5" BMI: 22.5 Pulse: 92 Resp: 18 Temp: 99.8°F
Constitutional: Normal.
ENT: Auditory Canals: Normal bilaterally.
Tympanic Membranes: Normal bilaterally.
Ears: Normal bilaterally.
Nose: Normal.
Lips, Teeth, Gums: Normal.
Oropharynx: Normal.
Pharyngeal Walls: Bilateral red swollen tonsils.
Neck: Normal.
Cardiovascular: Normal/Negative.
Respiratory: Normal/Negative.
Gastrointestinal: Normal/Negative.

Do you see the difference? Now the constitutional exam says "normal" instead of "Normal appearing" and I left off the lymphadenopathy from the exam. Now if your auditor audits you using 1995 guidelines, she will say you do NOT have enough for a Detailed Physical Exam. Because it requires at least 2 organ systems, both of which cannot say simply "normal" or "negative".

This is extremely important as a take away message. The key to a detailed exam is put details in at least 2 organ systems. I realize that is rather simplistic, but it is very important if you have done the work.