99213 yipee!!! Level 3 established visits.

According to EM university, in 2003 this code was used 56.7 percent of the time for internal medicine coding. It is no surprise that we like this "middle of the road" code. The problem is, just because we think it is middle of the road, doesn't make it so. In fact, I would say that the 99213 is so remarkably similar to the 99214 that you may be surprised how very many 99214s you are missing by picking the road most traveled.

Let's take a look at the anatomy of the 99213..

The 99213 is a visit with an established patient that you have seen in the LAST 3 YEARS......which requires a certain level of work and documentation. These requirements are:

1. An "Expanded" Problem focused History
2. An "Expanded" Problem Focused Examination
3. Medial Decision Making of Low Complexity

As you can see, this is made to look like the 99212 except "Expanded" which is why people think it is, to quote Goldilocks......"Just Right"

I beg to differ. In fact I think once you have the needed elements for a 99213 you may be surprisingly close to a 99214.

It all comes down to the documentation.

Lets look at each Element

• The "Expanded" Problem Focused History

What the hell does that mean????

This history requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. No PFSH is required.

Are you telling me that you don't do a review of Past Family, Medical or Social History with each patient? Isn't that what they want us to do with medicine reconciliation??

So likely you will exceed this requirement. An ROS of ONE system? Why do just one? I can think of a million reasons why even simple complaints need more than this.

• An "Expanded" Problem Focused Examination

Do you remember bullets? Not dodging them.....hitting them. In the 1997 physical exam rules a bullet system divided organ systems up into the sub exams...i.e. Conjunctivae, Sclera, Fundus for the eye.....

In the "Expanded" Problem Focused Examination you need, 6 bullets from ONE or more organ system......
Vitals signs? 1 Bullet
General Appearance? 1 Bullet

So all you need to do after this is examine 4 other "things" in the same or other organ systems.
Don't remember bullets? You can read about them by clicking here.

The problem is that to reach the next level, you need a much more comprehensive exam. But, the big kicker is that with established patients 99212, 99213, 99214, 99215 you only need 2 out of 3 categories to bill at the highest level. So you may qualify for a 99214 without doing that thorough an examination......Don't let your "Gut" tell you what to code.

The third category as always is the Medical Decision Making........otherwise known as the MDM

In this case, for the 99213 you need low complexity medical decision making......this is what bugs me.........just because your patient is "middle of the road" doesn't mean his MDM is.....

Which is the point that is being made here by the AMA. Is "Low Complexity Medical Decision Making" middle of the road for what you do? Probably not. Diabetes? Not really low complexity. Hypertension, a lot of the time this is not low level either. I view low level like the AMA views low level...In essence, the patient could come in with just ONE chronic problem, Which is STABLE and you make the MDM case. We start with the Points........Yes, MDM is divided up in 3 parts

1. Problem Points-In this case, you need 2 problem points? Do you remember the points per problem? You can review them here.

2. Data Points-These points are for data you review or order. In the 99213 you need 2 of them as well. You can review them here.

3. Risk-I really love this one. Low risk is "Only Marginally Higher than Marginal Risk" WTF? Ok, so just about everything outside of bug bite qualifies as at LEAST Low Risk. Which means, you probably are undercoding if you select 99213....

You should always ask yourself as you put 99213 down on the superbill........Is it really JUST a 99213? Chances are, you would be incorrect and it is in fact a 99214. Remember, just hitting MDM and History gets you a 99214 instead of all 3 being required in the New Patient 99204.

Want to see a 99213?

Here we go,

A 56 year old man present for follow up of well controlled hypertension wishing to change medications. He has absolutely no other complaints......

Anything above and beyond and you should start thinking about a 99214.

Did I just blow your mind? It did mine the first time I saw this.......

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99212 and You......

In keeping good faith with the readers of this blog, I am going to move to a "Level 2" Established patient visit. E and M University has some stats from 2003 on this, which may or may not be useful.....

Only 6.7% of Internists used this code in 2003. My guess is that it still is that way....

Why? Well, so often we do more work than the 99211 and 99212. Why? Well, this code requires

1. A problem focused history

2. A problem focused exam

3. Straightforward Medical Decision Making

Do you all remember how each of these categories is judged?

History is judged on:

A. Chief Complaint

B. HPI

C. Review of Systems

D. Review of Past Family, Social, Medical History.

A 99212 requires a Problem focused history which means you have to document a Chief Complaint and ONE HPI element. Just One.

What are the HPI elements? Well first, you need to know that there are only 2 types of HPI-Brief and Extended. What's the difference? Glad you asked. The difference is HUGE and I just told you what was required for Problem Focused.....

Now the elements

A. Location
B. Quality
C. Severity
D. Duration
E. Timing
F. Context
G. Modifying Factors
H.Associated Signs and Symptoms

That's it......you ONLY need one for a problem focused history. But for anything else you need 4 Elements, or the status of 4 or more chronic problems.

Think about it. A patient has pain, we ASK about PQRI (That's 4 BTW) but do we ever document 4? We should.

Now on to the problem focused exam.....

This is probably one of the funniest of them all. Problem focused exam requires ONE Bullet in ONE organ System........

Do you remember the Organ Systems? You can read about them and the bullets at this old post of mine.

But that would be tantamount to say. I took the Vitals......or I heard the heart.
We obviously are doing much more than that. Which is why most often our physica exams fall in the Expanded Problem focused, where you require 6 bullets in one or more organ systems. BTW you get 1 bullet for Vitals and One for General Appearance. Which you should do every time! Then you listen to the heart. Murmurs? No. 1 bullet, PMI shift No? 2 Bullet that's 4 bullets. So do you think you could get 2 more? Yes, most often we do. Which is why you rarely use the Level 2 99212...

In fact most things when a patient follows up are 99213 OR 99214 which will be covered shortly.....

But lastly in case you didn't make one of the previous 2 categories....you always have medical decision making. In the case of 99212 the level of decision making is straightforward medical decision making. Which in essence means you didn't need t o review or to think.....

What is straightforward MDM?

Straightforward Medical Decision-Making is the lowest level of Medical Decision-Making. It is impossible not to qualify for it.

It requires that you meet 2 of the 3 categories with One Point in each OR one category and MINIMAL Medical Risk.
What does that entail? Well, you can review my medical decision making post or you can just see right here

MDM is broken up into Problem Points, Data Points and Risk of Morbidity or Mortality from Disease.

Problem Points are
4 Points-New Problem, New Work up
3 Points-New Problem, No Work Up
2 Points-Established Problem, Worsening
1 Point-Established Problem, Stable

Data Points are
2 Points-Independant review of EKG or Radiology or Specimen
2 Points-Review of Old Records
1 Point-Ordering or Reviewing Labs
1 Point-Discuss results with OTHER physician
1 Point-Ordering tests (EKG/CXR/Cath)
1 Point-Decision to obtain old records

Risk in this case is Minimal Which means "Self limited or minor problem"
Risk is determined by 3 Things
1. Presenting Problem
2. Diagnostic Procedures
3. Management Options Selected

Still Conufsed? You can check the Table of Risk at EM University for further clarification.

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Do you risk stratify?

When you have a new patient, do you do a Framingham or Reynolds risk calculation?

When you have a postpartum follow up, do you do a depression screen?

When you have a geriatric patient, do you do a safe driver evaluation?

Do you calculate the risk of diabetes for patient that have family history of DM2?

If you do any of these things, then you qualify to bill for a 99420. 

A Wha? Yes, most coders that I have asked have no clue what this code is. 

99420 is defined by the AMA as "Administration and Interpretation of health risk assessment instrument"

All of my new patients get a Reynolds Risk upon return visit after I have their labs to calculate this risk.....

They all get billed for a follow up patient visit AND a 99420. They may also get other services, but they ALL get a Reynolds Risk.  

Why? It helps me know when to treat lipids and what preventative therapy to use. So why oh why wouldn't you use these tools? In fact, I argue it is the standard of care to use these tools......

And Now, you can bill for it. And get paid!

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Sitck with the Outpatient Codes, Please. 99211

Ok, Ok. I asked a read this week if they would rather have me review further inpatient or out patient codes. They begged me to stick with outpatient codes. So In response to that, no problem.

I figure I can walk you right through some outpatient cases which will help understand how your return patients match up. But first, let's talk a little about the established patient. This is defined as someone who has been seen by you or a physician in the same specialty in your group within the previous three years.There are five levels of care for this type of encounter which all require documentation of TWO out of THREE key components.

These are the absolute same components as you will see for most E and M visits.....

Yes, our lovely friends History, Physical and Medical Decision Making (MDM)

These components are broken down into several subgroups which in the end ultimately determine how much you get paid for Evaluation and Management codes.

The best part about established patients is that you do not have to meet such a high barrier to bill at the higher levels. Instead you only need 2 of 3 components to be at the highest level of your biling. Which is a heck of a lot nicer than the 99205 trainwrecks which require 3 of 3......

Let's talk about the simplest of these today. The 99211. The 99211 was designed as a quick 5 minute visit for follow up of one issue. In fact, this issue was not even thought to incur actual physician to patient face time.

This is a stable and acceptable BP check, done by nurse or PA. Let's look at it.

A 57 year old man comes to the office for a BP check. It is 120/80.....perfect. 

The patient has NO OTHER COMPLAINTS OR NEEDS at this time. I repeat, the patient has NO OTHER COMPLAINTS OR NEEDS at this time.

If he has ANYTHING ELSE....this code is not for him and he should be seen by an MD...... 

99211 equals one problem, no change in management or simple change in management. 

This visit does not require any hurdles. In fact the AMA considers this a 5 minute episode.....so If you have gone past 5 minutes, you need to look at other codes. In short, NO ONE REALLY CODES a 99211. In 2003 according to E/M University, 5% of all office visits were this code and the average reimbursement was 21 USD.

Take Home Point, If you've spent more than 5 minutes, you shouldn't use this code.

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The lovely 99205, Only for Trainwrecks!

Today I want to cover the 99205......but first I think it is appropriate to give you the clinical case prior to boring you with the detail.....That way we can go blow by blow through the case and pick it apart.

The Scenario: 

You see a 65 year old man for the first time who is complaining of a 20 pound weight loss, dysphagia, and abdominal pain. His past medical history includes DM2, CAD, OA, Chronic Bronchitis, HTN, GERD and Hyperlipidemia. He takes 8 medications and hasn't seen a doctor in 19 months.

Like I said, 99205 is ONLY for the trainwrecks. There is no way you could even think about upcoding to a 99205. No Way!

I repeat   The patient would need to have a severe exacerbation of a chronic problem or an acute illness which threatens life or bodily function to qualify for this level of risk

So let's go through the things that make this different from a 99204 first.

Medical Decision Making (MDM) of High Complexity, that's all. Nothing Else....

But boy, what a bar you are going to have to meet on this one.

What does high complexity MDM entail?

1. Number of Diagnoses or Management Options must be "Extensive"

2. Amount/Complexity of Data Reviewed must also be "Extensive"

3. Lastly, the Risk of MandM must be high....

We have reviewed these a little before, but let's recap.

Remember how I said MDM is difficult and is judged by 3 variable?

These Are Also Called:

A. Problem Points-In this case you need 4 points

B. Data Points-For the 99205 you also need 4 points

C. Risk-This has to be HIGH RISK,

High risk essentially means a condition that is placing the patient in IMMINENT threat of their life. I think you know what these are....but for the non-physicians out there let me give you a hint

1. Myocardial Infarction, but not stable Angina

2. Renal Failure, but not Renal Insufficiency

3. Trauma

4. TIA or Stroke

5. Pulmonary Embolism

6. Status Asthmaticus but not mild exacerbation

I think you get where I am going here......

99205 is only for Trainwrecks....I repeat only for Trainwrecks.......

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RACs and RUCs and 99204s, Oh My!!!

Today is the next installment in the New Patient Office Visit Series.

We will be covering the 99204 CPT code. In 2003 it was selected 30% of the time for the new patient encounter.....which means just about 65% of patients fit into the 99203 or 99204 zone. My guess is that by the time we are done, you will be using 99204 much more than not.

So what is a 99204?

99204 requires these 3 components

1. A "Comprehensive" History

2. A "Comprehensive" Examination

3. Medical Decision Making of "Moderate" Complexity

Once again the definition of Moderate and Comprehensive are key here.

Moderate Complexity Decision Making is often audited and requires:

A. Multiple Diagnoses or Management Options. AMA doesn't list the exact number here but E and M University has a good wrap up 

The take home is that new problems with additional work up gets a maximum of 4 problem points. If it is a new problem with no further work up it is 3 points.

You can feel pretty confident  billing 99204 here if you have 3 points here AND

B. Amount and/or complexity of data reviewed has to be moderate as well. 

In this case you would need 3 data points reviewed. Ordering clinical lab tests counts as 1 point. So does ordering a radiology test, the same with EKG.

Discussing the results with a physician gives you a measly one point as well. But independent review of the specimen, image or tracing gives you 2 points......

So if you looked at the film, document that you looked at the film....or EKG.....

Review and summation of Old Records ALSO gives you 2 points.......

You can consider yourself getting warm here if you have 3 data points here AND 3 problem points.......

C. Moderate Risk of Complications, Morbidity or Mortality.....Well, what does that mean?

You can turn to the "Table of Risk!"

This basically indicates that you have one thing of 3 categories......

Category A-Presenting Problems

One or more chronic illnesses with mild exacerbation

Two or more stable chronic illnesses (HTN and Hyperlipidemia)

One Undiagnosed New problem

Acute Illness with Systemic Symptoms

Category B-Diagnostic Procedures

Stress Test or Fetal Stress test

Diagnostic Endoscopies

Deep Needle or Incisional Biopsies

Cardiac Cath

Fluid removal from Body Cavity

Category C-Management Options Selected

Minor surgery

Elective Major Surgery

Prescribing Medicines

IV fluids

Closed treatment of a fracture

So, you need one of each category to qualify Risk as a moderate data point

Listen, this system is complicated here.....My gut tells me that you should not count on using Risk as 1 of your 2 required points to qualify MDM as moderate complexity.

My take home on MDM is-Always review your own data, Always review old records, 

Always document new problems and demonstrate your work up of them......If you do these things you will likely qualify for moderate MDM

Now that's over, let's look at a Comprehensive Exam

Comprehensive is defined as 

1. "A general multisystem examination"

2. " A complete examination of a single organ system"

Organ systems are:

Eyes

Each Extremity, I repeat EACH Extremity

Ear, Nose,Throat and Mouth

Eyes

CV

Respiratory

GI

GU

Musculoskeletal

Skin

Neurologic

Psychiatric

Heme/Lymph

If you set up a template of your exam as such, you will do well in documenting these events. The take home here is that to be complete you would need 2 bullets for each of the 9 systems.......Ah silly coders, they have to be so precise in defining complete.....do they really know what complete means?

I go over bullets and the exam in prior posts 

This is a gimmee here. Anyone would do this for a new patient......Anyone......Count Complete physical as one of the 2 Categories filled

Lastly,

Complete History. This bugger is considered the Highest Level of History. Which means often people try but fail at performing this.

This history includes:

1. Chief Complaint

2. "Extended" HPI

3. Review of systems related to the problems in the HPI PLUS all other systems

4. COMPLETE Family, Social and Past Medical and Past Surgical History

I will go through each in detail, but suffice to say.....you should be doing these things for ALL new patients if you want to code a 99204.....I actually do this for ALL of my new patients....I will explain why shortly...

The big question here is likely to be What is a COMPLETE PM/PS/Soc/FamHx (PFSHx)......One thing it isn't is NonContributory.......It is at a minimum-Parents, Siblings AND Children! I do grandparents too!

This includes Medicines and Allergies! I repeat, this includes medicines and allergies....

I plan on covering this in another post, but just keep these tips in mind.

Is the patient married? Are they employed? Have they had education? Do they have exposures? Sex? Drugs? Rock and Roll? 

Remember, nearly all outpatient codes require some elements of this here. So it is just good sense to do this at EVERY encounter.....

And most importantly, the PFSHx can be taken by another person, OR EVEN a Form......

What does this look like in real time? 

Initial visit for a 59 year old woman with HTN, Obesity, OA. She has a complaint of palpitations with some occasional dizziness. Her PMSFHx includes TAHBSO for DUB 15 years ago. She has not been seen for 5 years.

If this new patient is also here for a complete physical exam....there is something I need to share with you.....it is called Modifer 25....the name of this blog! 

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How a code becomes a check......

What I love about learning this whole system is that you begin to understand that people who are not doctors are always trying to quantify what you do and how you do it. Things such as RVUs turn a clinician into a blue collar worker. 

It is one of the most disgusting things that I have seen. That's why I gave up working for anyone who wishes to tell me how productive I am. At the end of the day, just ask my patients, they will tell you how productive I am......

This coding and auditing system cracks me up. Here you have a bunch of people from the AMA, HCFA, and other organizations trying to explain what we do in a very, VERY detailed way, without having the direct professional understanding of how we do it.

Granted, there are some physicians on these panels......but they are NOT all specialties or the majority. CPT was started in the late 60s and encouraged to use as a data reporting tool, to "standardize" what we do......sounds eerily familiar to PQRI.....

It was then accepted by Medicare in 1983 as the mode of reporting for reimbursement......that's when hell came on earth.......slowly...

The CPT manual is updated annually through an editorial review process. The CPT Editorial Panel meets 3-4 times per year to review requests received from specialty societies, manufacturers and individuals. The Panel is supported in its deliberations by a larger body of CPT advisors, known as the CPT Advisory Committee

This body, it is oft complained as existing to serve the specialists and not the generalists.....This could be seen as sour grapes, or it could represent a serious lack of voice....

Either way, you have a coding committee who may not represent all parties.....Which is not  an equitable or reasonable position to take.

That being said

Once a coding change is accepted by the CPT Editorial Panel, the next step in the CPT process is to determine the reimbursement for the code, through a survey of physician work and determination of direct practice expense (PE). The survey results are submitted to the RUC for negotiation for a mutually acceptable value to be submitted to CMS for final approval and publication in the Federal Register Final Rule. The approved CPT code and their associated RVUs are then published. 

You may be asking......What is the RUC and What is an RVU

The RUC is:

The Relative Value Update Committee, a decision-making body which reviews all surveys of physician work values (52 percent of the total RVU for a service/procedure) and practice expense or PE (44 percent of the total RVU for a service/procedure) and makes recommendations regarding these components to the Centers for Medicare and Medicaid Services (CMS) for reimbursement  determination. Members of the RUC are appointed by national medical specialty societies.

What in an RVU?

An evil way to turn us into worker bees, rather than professionals....

If you really must know, then you can read about it here.

Relative value units

Although several relative value systems are recognized and used nationally, the most identifiable system is the Resource-Based Relative Value Scale, or RBRVS. The RBRVS system was adopted in 1992 by CMS as a method for setting Medicare reimbursement levels. Under the RBRVS methodology, services are assigned a numerical value or weight, which is relative to all other codes. The numerical value, or relative value unit (RVU), is actually made up of three component units — designated for work, practice expenses, and malpractice expenses.

To set the Medicare allowable rate, the component units are factored by corresponding geographic indices, summed, and then multiplied by a standard conversion factor. Basically, it is a lot of economic shenanigans to devalue what we do....

 Each year, CMS makes changes to the RBRVS component units, based upon the introduction of new CPT codes, changes to code values by the American Medical Association (AMA) and specialty societies’ RUC (Relative Value Update Committees), and government budget constraints and indices.

For the last decade or so, Mediare has been trying to cut payments to physicians, despite practice expenses and malpractice expenses going up each year. Funny really when you think that their equation relies so heavily on these 2 factors. The real issue lies in the standard conversion factors......

With one simple change of an equation, the entire system, which is already on its knees, could be dropped to the floor.

So, the question becomes, "So this is Medicare and Medicaid, what about regular insurance?"

The AMA receives approximately $70 million annually from licensing fees for anyone wishing to relate RVUs with CPT codes, making them reluctant to allow the free distribution of tools and data that might help physicians calculate their fees accurately and fairly.

I.E. the AMA makes millions off of the insurers who want to use the governmental system for setting their fee schedules....

So, the AMA is in bed with the government AND the commercial insurers.....to "help the doctor-members"

But just like most politicians who go to Washington, this system is corrupted. And we need to fix it, by learning the system and using it to our advantage to get paid fairly for what we do.

That my friend is how we turn a code into a check.....I am going to post links to each of these important boards.

About the RUC only 5 of the 29 are primary care. 

Not exactly the 2/3rds majority required to change payments....Did you know that the AMA could have been threatened with Anti-Trust laws by telling the public what this committee does?

I can't find the membership of the CPT editorial committee.....does anyone have this information???

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What's the difference in physical exam types? Bullets and 1997.

I actually have seen these in a few shrouded away places...But most physicians don't know these rules......You see, in 1997 the EM physical exam rules were updated from the loosey goosey rules of 1995.....They rely on these "Bullet Points" which allow atomatons to check the boxes and audit our charts much easier. It also allows for the automation and creation of EMR exam forms....i.e. "check the box" or "Check the Bullets"

Here are the 1997 Physical Exam Rules, Couched with levels of physical examination.

1997 Physical Exam Rules General Multi-System Exam 1997 Problem Focused Exam One to five bullets from one or more organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Lungs: CTA  CV: RRR, no MRGs  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart) Total bullets = four (although only one to five bullets are required)  1997 Expanded Problem Focused Exam  At least two bullets from six organ systems OR 12 bullets from two or more organ systems  Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant Lungs: Clear to auscultation  CV: RRR, no MRGs  Abdomen: Soft, nontender  Extremities: No peripheral edema  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart)  (1 bullet for examination of the abdomen)  (1 bullet for examination of extremities for edema)  Total bullets = six  1997 Detailed Exam  At least two bullets from six organ systems OR 12 bullets from two or more organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Neck: FROM, supple  Lungs: Clear to auscultation  CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits  Abdomen: Soft, non-tender; no masses or HSM  Extremities: No peripheral edema or digital cyanosis Skin: no rash, lesions or ulcers  Psych: Alert and oriented to person, place and time  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for examination of neck)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart)  (1 bullet for assessment of carotid arteries)  (1 bullet for examination of the abdomen)  (1 bullet for examination of liver and spleen)  (1 bullet for examination of extremities for edema)  (1 bullet for examination and/or palpation of digits and nails)  (1 bullet for inspection of skin and subcutaneous tissue)  (1 bullet for brief assessment of mental status—orientation) Total bullets = 12  1997 Comprehensive Exam  Two bullets from EACH of nine organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA  HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate  Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy  Lungs: CTA, with normal respiratory effort and no intercostal retractions  CV: RRR, no MRGs  Abdomen: Soft, non-tender; no masses or HSM  Extremities: No peripheral edema or extremity lymphadenopathy Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules  Psych: Appropriate affect, alert and oriented to person, place and time  Systems and Bullets  Constitutional  (1 bullet for three vital signs)  (1 bullet for general appearance)  Eyes  (1 bullet for inspection of conjunctivae and lids)  (1 bullet for examination of pupils and irises)  Ears, Nose, Mouth and Throat  (1 bullet for external inspection of ears and nose—“atraumautic”)  (1 bullet for examination of oropharynx)  Neck  (1 bullet for examination of neck)  (1 bullet for examination of the thyroid)  Respiratory  (1 bullet for auscultation of lungs)  (1 bullet for assessment of respiratory effort)  Cardiovascular  (1 bullet for auscultation of heart)  (1 bullet for examination of extremities for edema or varicosities)  Gastrointestinal  (1 bullet for examination of the abdomen)  (1 bullet for examination of liver and spleen)  Lymphatic  (1 bullet for examination of lymph nodes in neck)  (1 bullet for examination of lymph nodes in extremities)  Skin  (1 bullet for inspection of skin and subcutaneous tissues)  (1 bullet for palpation of skin and subcutaneous tissues)  Psychiatric  (1 bullet for description of patient’s judgment and insight)  (1 bullet for brief assessment of mental status—orientation)  Total systems = 10 (although only nine are required)  Total bullets = 20 (although only 18 are required—two in EACH of nine systems)  Organ Systems  The 1997 E/M guidelines recognize the following organ systems:  1. Constitutional  2. Eyes  3. Ears, nose, mouth and throat  4. Neck  5. Respiratory  6. Cardiovascular  7. Chest (breasts)  8. Gastrointestinal (abdomen)  9. Genitourinary (male)  10.Genitourinary (female)  11. Lymphatic  12. Musculoskeletal  13. Skin  14. Neurologic  15. Psychiatric Physical Exam Bullets  Constitutional      1)   Three vital signs     2)    General appearance Eyes      1)   Inspection of conjunctivae and lids      2)   Examination of pupils and irises (PERRLA)      3)   Ophthalmoscopic discs and posterior segments  Ears, Nose, Mouth, and Throat      1)   External appearance of the ears and nose (overall appearance, scars, lesions, masses)      2)   Otoscopic examination of the external auditory canals and tympanic membranes      3)   Assessment of hearing      4)   Inspection of nasal mucosa, septum and turbinates      5)   Inspection of lips, teeth and gums      6)   Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck      1)   Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)      2)   Examination of thyroid  Respiratory      1)   Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)      2)   Percussion of chest (e.g., dullness, flatness, hyperresonance)      3)   Palpation of chest (e.g., tactile fremitus)      4)   Auscultation of the lungs Cardiovascular      1)   Palpation of the heart (location, size, thrills)      2)   Auscultation of the heart with notation of abnormal sounds and murmurs      3)    Assessment of lower extremities for edema and/or varicosities      4)   Examination of the carotid arteries (e.g., pulse amplitude, bruits)      5)   Examination of abdominal aorta (e.g., size, bruits)      6)   Examination of the femoral arteries (e.g., pulse amplitude, bruits)      7)    Examination of the pedal pulses (e.g., pulse amplitude) Chest (Breasts)      1)   Inspection of the breasts (e.g., symmetry, nipple discharge)      2)   Palpation of the breasts and axillae (e.g., masses, lumps, tenderness) Gastrointestinal (Abdomen)      1)   Examination of the abdomen with notation of presence of masses or tenderness      2)   Examination of the liver and spleen      3)   Examination for the presence or absence of hernias      4)   Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids,            rectal masses      5)   Obtain stool for occult blood testing when indicated Genitourinary (Male)      1)    Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)      2)   Examination of the penis      1)   Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness) Genitourinary (Female)  Pelvic examination (with or without specimen collection for smears and cultures, which may include:      1)   Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)      2)   Examination of the urethra (e.g., masses, tenderness, scarring)      3)    Examination of the bladder (e.g., fullness, masses, tenderness)      4)   Examination of the cervix (e.g., general appearance, discharge, lesions)      5)   Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)      6)    Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) Lymphatic  Palpation of lymph nodes two or more areas:      1)   Neck      2)    Axillae      3)    Groin      4)   Other Musculoskeletal      1)   Examination of gait and station      2)   Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia,           infections, nodes) Examination of the joints, bones, and muscles of one or more of the following six areas:      a)   head and neck      b)    spine, ribs, and pelvis      c)    right upper extremity      d)   left upper extremity      e)   right lower extremity      f)    left lower extremity The examination of a given area may include:   1)   Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation,   2)   defects, tenderness, masses or effusions  3)   Assessment of range of motion with notation of any pain, crepitation or contracture  4)  Assessment of stability with notation of any dislocation, subluxation, or laxity   5)  Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any  atrophy or abnormal movements Skin      1)   Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)     2)   Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic      1)    Test cranial nerves with notation of any deficits      2)   Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)      3)   Examination of sensation (e.g., by touch, pin, vibration, proprioception) Psychiatric      1)   Description of patient’s judgment and insight Brief assessment of mental status which may include     1)   orientation to time, place, and person     2)   recent and remote memory     3)   mood and affect 1997 Specialty Exams can be found here. So there you have it......if you have the time to read through this and understand, you can see that the more you document the better. If you do use an EMR, you probably all ready have this. But if you are on paper, you should update your exam form to include the systems and perhaps even the bullets. This will prompt you to examine "All the pertinent systems" Want to join us? Email us at modifier25@gmail.com