Level of Exam - I was wondering

[jmcalhaney]

I was wondering if I could get an opinion on what level of exam you think this might be:

Wt: 195 lbs. Gen: NAD. HEENT: NC/AT, EOMI, PERLA, No scleral icterus. Throat clear. CV: S1 and S2 w/o murmur, rub, or gallop. Chest: clear to ausculation and percussion. There is no spider telangiectasia. ABD: Normoactive bowel sounds, soft, nontender. No hepatosplenomegaly, no rebound. There is no ascites. BACK: Nontender RECTAL: Deferred. Neuro: Alert and oriented x 3, nonfocal. Extremities: There is no cyanosis, clubbing, or edema.

I have found that for the 95 guidelines, the physician examined Constitutional, HEENT (counted as 1), Respiratory, Cardio, GI, Neuro, and Musculoskeletal. The physician has coded this as a comprehensive exam and each one of his exams is almost identical to this note. This results in him coding for a comprehensive each time and I think that he may be overcoding as a result of this. Any opinions are appreciated. Thanks.

 

[jmcpolin]

I count 7 exam constitutional and HEENT are 2 separate

 

[MikeEnos]

I would consider this to be a comprehensive exam, though it is close. Here's what I see:

(1) Constitutional: Wt: 195 lbs. Gen: NAD.
(2) HEENT: NC/AT, EOMI, PERLA, No scleral icterus.
(3) Throat clear.
(4) CV: S1 and S2 w/o murmur, rub, or gallop.
(5) Chest: clear to ausculation and percussion. There is no spider telangiectasia.
(6) ABD: Normoactive bowel sounds, soft, nontender. No hepatosplenomegaly, no rebound. There is no ascites.
(7) BACK: Nontender
(6 again) RECTAL: Deferred.
(9) Neuro: Alert and oriented x 3, nonfocal.
Extremities: There is no cyanosis, clubbing, or edema.

I count the following organ systems: (1) Constitutional (2) Eyes (3) Ears, Nose, Throat (4) Cardiovascular (5) Respiratory (6) Gastrointestinal (7) Musculoskeletal (8) Neurological

You also have the following body areas: Head, and possibly LUE and RUE Extremeties. It's a moot point though because you can't use body areas for a comprehensive level of exam, but you can use them for PF, EPF, and Detailed. So what we have here is certainly at least a detailed level of exam using the '95 guidelines, and I would give them credit for a comprehensive level of exam.

What concerns me is that you say each of his exams are almost identical. There's a potential there for "copy and paste" notes, "cloned" notes, or "point and click" notes. There should be something unique about each one, and certainly I would be concerned if he's documenting the patient's head, eyes, rectal exam, etc if the patient came in for a sprained ankle or sore knee.

 

[jmcalhaney]

I count 7 exam constitutional and HEENT are 2 separate

I know that constitutional and HEENT are 2 separate elements. I was counting HEENT as only 1 Organ system instead of using Eyes and ENT.

 

[dclark7]

According to the Medicare E/M Services Guide, for a comprehensive exam you can only count organ systems, not body areas and organ systems. I do count 8 organ systems in your note.
1) Constitutional - 195 lbs, NAD
2) Eyes - EOMI, PERLA, sclera anicteric
3) ENT - throat clear
4) Skin - no spider telangiectasia
5) Cardiovascular - S1, S2 w/o murmur, rub or gallop, no cyanosis, clubbing or edema
6)Respiratory - Clear to auscultation and percussion
7) Psych - Oriented x 3 (some count as neuro, can't count for both)
8) GI - Normoactive bowel sounds, no hepatosplenomegaly, no ascites

You can count the extemities (clubbing, cyanosis, edema), the HEENT NC/AT and back as body areas, but they do not count toward a comprehensive exam. You cannot count the rectal, it was deferred for whatever reason which means it was not examined.