Illness with normal exam?


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I have a Dr in my office who is seeing patient's with things like URIs, wheezing, OM, etc. He always has a normal exam on every illness. HPI and MDM support the illness, but there is never any thing abnormal noted in an exam.

We use eCW as our EMR system, so all the Drs have to do is push a button to drop their complete exam into the record.

I had been pushing back to have this Dr load addendums stating what was abnormal in the exams that supported the MDM, but he has been refusing to load addendums. My boss and I looked in several sources and cannot find anything at all that states the exam has to support the diagnosis, even though it seems like common sense.

Does anyone know where to find documentation stating that the exam MUST match the diagnosis, or am I just being unreasonable?

I know the rule says he only needs two out of three components, so the exam can pretty much be disregarded, but it drives me crazy that he's just dropping all these normal exams.
Hi Steph,

You clearly see he is either copying and pasting his normal exam or using a favorite.

You won't find black & white guidance stating the exam must match the HPI etc etc however, the risk here could be presented to your physician as a malpractice risk to his medical license and your practice if he continues.

I would prepare examples of his PE where they are identical and normal and the HPI is clearly reflecting a sick visit. I would raise the point that the patient is there because they are sick. By stating every exam is normal he is reporting false information into a legal document, claiming clinical responsibility for organ systems he never even examined, and putting himself at great risk for a malpactice case or BME investigation.

Imagine he says they have a completely normal nuero exam and the patient leaves the office and has a stroke. How about wheezing with a normal respiratory exam and the patient dies later that night from pneumonia. You can bet if something tragic happens to a patient and he was the only physician they may have seen that day, he will no doubt have to support his "normal" exam.

He should state deferred if no exam done regarldess of key components, codes, billing, etc.
Oh he is absolutely using a template for his exam, on the system we use, eCW, the Drs can have preset exams that they just click on and it drops it already pre-filled out. Our compliance department says it's ok, but I think it makes it to easy to accidently (or on purpose) falsify things.

He is treating the illnesses appropriately, the exams are just not reflecting any illness. I agree that there is possible risk if a child has an illness that a documented abnormal exam could have caught. It just seems rediculous that there isnt anything in writting stating the obvious point that the exam should reflect the illness. Maybe it's something they figured was a given, LOL, leave it to a Dr who hates to document to be able to find a way around it.
Your compliance department is correct in stating that there is no regulation that states they can't use copy & paste or favorites that is true however, I would take the false normal exam as placing your practice and patients at risk.

There could definately be instances where patients would still be at risk even though he is treating the symptoms i.e.; earache turns out to be a mass in the ear maybe malignant even....see where im going. Pt presents with earache, he gives amoxil, and says he examined the ears and they are normal. A month later ear still hurts and ER finds a mass inside the ear canal. You could come up with hundreds of real life scenarios.

Good Luck Steph
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This practice of copying exams or using templates that are exactly the same, is called cloning. This could quite possibly lead to an audit, take back and or penalties for "fraud". The payers are especially looking for this, so your provider really needs to be made aware of this. Hope this helps!
Absolutely correct it is called cloning... and the OIG has determined that this is an area targeted as a high level of concern. While the exam does not necessarily have to reflect the cc, it does need to be relevant to why the patient is there, afterall this is the physician's hands on portion of the visit. The cc is what the patient perceives is the problem, the exam is where the provider determines exactly what the issue is. So how can you have a patient that presents ill and the exam reveals nothing? So is he saying the patient is faking? or is the patient doing the exam themselves and the provider is taking their word for everything?
Trailblazers performed an audit and provided an excellent write up regarding assignment specifically of inpatient levels but you can use this as a guide for all types of levels..
Initial Hospital Care Medical Review Results
Date: (12/21/2011)
Notice ID: 14580
If you cannot locate the article you will need to post your e-mail so I can cut and paste it too you, It is fairly long and I have it in my class materials to use.