EM Exam components- does this meet a comprehensive exam?

amexnikki23

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Do you count 8 organ systems for a comprehensive exam? Patient is in a coma.

VITAL SIGNS: BP 100/60, HR 90, Intubated on vent, sedated. Weight 171 kg.
HEENT- face is cushingoid
CHEST: bilateral rhonchi
ABD: soft
EXT: legs show edema
NEURO: corneal and gag reflex absent. No movement or withdrawal to pain- upper and lower extremities.

(1. constitutional, 2. eyes, 3. ENT, 4. resp, 5. gastro, 6. neuro, 7. cardio or lymphatic [extremity edema] and 8. musculoskeletal [non-movement of the extremities as mentioned in the neuro exam… was looking at that as being neuromuscular]).

Also, where would you place "cushingoid" in the HEENT heading since this is endocrine based?
 

jdibble

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Do you count 8 organ systems for a comprehensive exam? Patient is in a coma.

VITAL SIGNS: BP 100/60, HR 90, Intubated on vent, sedated. Weight 171 kg.
HEENT- face is cushingoid
CHEST: bilateral rhonchi
ABD: soft
EXT: legs show edema
NEURO: corneal and gag reflex absent. No movement or withdrawal to pain- upper and lower extremities.

(1. constitutional, 2. eyes, 3. ENT, 4. resp, 5. gastro, 6. neuro, 7. cardio or lymphatic [extremity edema] and 8. musculoskeletal [non-movement of the extremities as mentioned in the neuro exam… was looking at that as being neuromuscular]).

Also, where would you place "cushingoid" in the HEENT heading since this is endocrine based?
This is definitely not a comprehensive exam. I do not see 8 organ systems mentioned in this note. For one thing, there is no mention of eyes or ENT. HEENT as the header cannot be counted toward a system unless there is mention of those systems separately - eyes and ENT. You cannot count the cushingoid face as that is not part of eyes or ENT. I also would not count non-movement as musculoskeletal as that appears to be the response of the neuro testing. I would count the "cushingoid" possibly under the lymph/heme/immune section as there is no Endocrine system - or it could be under constitutional for appearance. So, I count only 5 maybe 6 systems documented.

Any other opinions on the cushingoid face?
 

mitchellde

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The cushioned face would be part of appearance. Or possibly skin. However while you might have a detailed or comprehensive exam, the medical necessity for that exam must be demonstrated. So what is diagnosis. If the exam of areas like abdomens are not essential to the medical necessity for the encounter and the provider does not give any indication as to what the results of "abdomen soft". Would mean, then it is not relevant as an exam issue.
 

amexnikki23

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This is definitely not a comprehensive exam. I do not see 8 organ systems mentioned in this note. For one thing, there is no mention of eyes or ENT. HEENT as the header cannot be counted toward a system unless there is mention of those systems separately - eyes and ENT. You cannot count the cushingoid face as that is not part of eyes or ENT. I also would not count non-movement as musculoskeletal as that appears to be the response of the neuro testing. I would count the "cushingoid" possibly under the lymph/heme/immune section as there is no Endocrine system - or it could be under constitutional for appearance. So, I count only 5 maybe 6 systems documented.

Any other opinions on the cushingoid face?
This helps a lot. Appreciate the response. When I checked earlier there weren't any responses (well, it said 0 replies) so I posted this under EM as well. Thanks!
 

amexnikki23

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The cushioned face would be part of appearance. Or possibly skin. However while you might have a detailed or comprehensive exam, the medical necessity for that exam must be demonstrated. So what is diagnosis. If the exam of areas like abdomens are not essential to the medical necessity for the encounter and the provider does not give any indication as to what the results of "abdomen soft". Would mean, then it is not relevant as an exam issue.
Hi! The patient presented to the ER unresponsive brought in by family members. Patient was in a coma for a few days and this exam was performed while the patient was in a coma. Several aspects of neuro were examined, but the other systems are pretty much one-worders. I know the providers have to meet all of the requirements for the comprehensive exam in order to bill a 99222, but I just can't see how a patient with abrupt neuro changes in a coma could be a 99221. Guidelines are guidelines though.
 

jdibble

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This helps a lot. Appreciate the response. When I checked earlier there weren't any responses (well, it said 0 replies) so I posted this under EM as well. Thanks!
Your welcome! I understand your frustration with only being able to bill a 99221 because of documentation. My providers are not very thorough with their documentation on their consults and I have the same issues - a patient clearly with medical necessity that would allow a 99222 or even a 99223, but they don't document a ROS or family history or only do an expanded problem focused exam and I am forced to drop the level to a subsequent hospital code!
 
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