Wiki Exam components - constititutional must it be relevant to CC?


Portland, OR
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I work for a dermatology office. The physicians usually assess the patient's general appearance- "Patient appears well nourished, developed, stated age and not in apparent distress". For the exam portion under 97 guidelines we count that as "constitutional" bullet. One of our coders went to a conference where she heard we should not count it toward the exam if it is not "relevant" to the CC.

Have you heard this? If a patient presented with warts or fungus or dandruff. Could it be argued as relevant?
In theory, you shouldn't count elements of documentation that are irrelevant to the problems being treated. In practice, though, my experience is that if you put coders in the position of trying to make individual decisions about whether or not each element of a note is or is not relevant is setting yourself up for problems. For one thing, it's generally outside the scope of coding to know and it will tremendously slow down coding productivity, and for another, it can create a difficult working relationship with providers if a coder is reducing their levels and revenue based on their own independent judgments of the providers' work. My recommendation is, if you have concerns that you could be up-coding due to possibly irrelevant information being counted, the best approach is a discussion with the providers to get their input and to make a joint decision as to whether this is causing the charges to be inflated and at risk in an audit, or whether it is clinically relevant and defensible as important information to include.

Hope this helps some - these aren't easy questions to answer.
I agree with Thomas7331 that you should consult with the physician and that relevance is a rather gray area at times that isn't easy to answer.

In your example though this would be relevant in any medical office in fact. General appearance under constitutional can give insight to the state of living conditions, access to necessary nutrition, or adequate access to necessary material goods and prompt the physician to inquire further which is relevant to all MDM by any physician before creating a plan of care. If the patient is not in the "norm" for appearance it could mean that the physician may have to change their plan for treating the patient. It could indicate a potential cause of noncompliance to the medical treatment which the physician will have to take in to account before making a plan. A physician wants to treat someone effectively and does not want to give them something they are incapable of following through.

All in all, if there is a question of relevance talk to the physician as they are the ones who are ultimately making those decisions of medically relevant and they can maybe give you further insight to the relevance of something that may not look like it really is. I hope this helps!