Wiki EM physical exam

[KristinM522]

I work for an orthopaedic practice that also has pain management doctors. Our pain dr's do what they call an "objective VISUAL exam" on new patients consisting of body areas like eyes, skin, respiratory, CV & abdomen. This part of the "exam" is strictly what they have observed while talking with the patient, no instruments are used and they aren't doing any physical tests to confirm their observations. The question is, is it acceptable to do a "visual" exam like this in pain management (in addition to their actual physical exam-if their is one) I am used the musculoskeletal docs and they only do whats pertinent to their extremity/body area and perhaps a constitutional and psychiatric exam but not all the rest. Since the pain dr's document these other body systems obviously it raises the level of EM they bill out. I am trying to find information from Medicare or another reputable source one way or the other to end the ongoing speculation of "can they or can't they" but not having much luck. Does anyone have any info that may be helpful here??

Thank you in advance!

 

[thomas7331]

All physicians I have ever worked with include the visual observations they have made during their encounter with a patient as part of their exam. As I understand it, this is part of a physician's training, which is to assess the patient's status as a whole, and does not have to be confined to a specific physical exam portion of the encounter. So there is nothing unusual about documenting these observations and including it as part of the exam.

The question you bring up here, though, is one of medical necessity. How many of those observations are truly relevant and necessary to the treatment of the patient's presenting problem at the time of the encounter, and does the addition of the extra detail inflate the level of the E&M to a higher level than is reasonable for what is needed to assess and manage that patient? As with all medical necessity, this is a clinical question that only a trained professional can fully answer. There has been a lot written about this topic in recent years, but there is no clear guidance for coders on this. It's a difficult question that ultimately requires the input of your providers. As a starting point, you can review some of the clinical examples from your specialty in Appendix C of your CPT book, and you may want to collect some examples of encounters where you feel the added documentation seems to inflate the code levels. Another good way to get input is to bring in an outside auditor to look at the notes. But ultimately, it's the providers who will be the ones that have to defend the medical necessity of what is in their documentation so they are the ones that will have to guide you on this. In my experience, there isn't any good black and white guidance for coders on when they should or should not disqualify portions of an E&M note as being medically unnecessary.

 

[KristinM522]

Thank you so much for your response! Everything you said here makes perfect sense to me and really how I make sense of it in my head. Our administration was/is concerned about the visual exams and if this meets the "criteria" as far as that goes. In my opinion, a pain dr has medical necessity to observe and document these findings on a new patient visit because ultimately, the patient is there to obtain a script. Whereas our musculo guys don't really need to make any observations of a patients eyes for instance, when they have a fracture or arthritis in a lower extremity. I tried to explain it this way yesterday, but the concern was still there. I am going to reach out to an outside auditing company like you suggested to get further confirmation.

I appreciate your help!

All physicians I have ever worked with include the visual observations they have made during their encounter with a patient as part of their exam. As I understand it, this is part of a physician's training, which is to assess the patient's status as a whole, and does not have to be confined to a specific physical exam portion of the encounter. So there is nothing unusual about documenting these observations and including it as part of the exam.

The question you bring up here, though, is one of medical necessity. How many of those observations are truly relevant and necessary to the treatment of the patient's presenting problem at the time of the encounter, and does the addition of the extra detail inflate the level of the E&M to a higher level than is reasonable for what is needed to assess and manage that patient? As with all medical necessity, this is a clinical question that only a trained professional can fully answer. There has been a lot written about this topic in recent years, but there is no clear guidance for coders on this. It's a difficult question that ultimately requires the input of your providers. As a starting point, you can review some of the clinical examples from your specialty in Appendix C of your CPT book, and you may want to collect some examples of encounters where you feel the added documentation seems to inflate the code levels. Another good way to get input is to bring in an outside auditor to look at the notes. But ultimately, it's the providers who will be the ones that have to defend the medical necessity of what is in their documentation so they are the ones that will have to guide you on this. In my experience, there isn't any good black and white guidance for coders on when they should or should not disqualify portions of an E&M note as being medically unnecessary.