Wiki New Patient Physical Exam under 2021 changes

[rthomas@impcna.com]

I know that a complete physical exam is no longer required for medical decision making but when it comes to new patients should a provider do a complete physical exam and not just what is relevant to the visit? Sometimes the documentation I have needed to support a code had been found in the PE. I want my providers to continue to give quality care but since the new E/M changes some of them have quit doing complete physical exams since its no longer required. For example a new patient came in for chest pain/pressure & difficulty swallowing, this was the PE
Constitutional:
general appearance- overall: in no acute distress, well developed and well nourished
Respiratory:
respiratory effort/rhythm- overall: no retractions
Should I just let this go or should I suggest or make a recommendation that new patients get a complete exam? We are a Primary Care, Internal Medicine & Pediatric Clinic Group.
All feedback and opinions appreciated.

 

[twizzle]

You cannot tell a provider to perform a complete exam on every new patient, nor is a complete exam indicated for every new patient (would you suggest a neurological exam or a GI exam for a patient with a bruised toe.....probably not? That is their call and they should do what they feel is medically appropriate.
The example you gave however does have shortcomings. If the patient had chest pain, listening to the heart would seem an obvious choice. If they had difficulty swallowing then checking out the throat might be a good place to start. Regrettably it is neither your place nor your job to suggest this to the provider.; they won't thank you for it.
What now matters in the office scenario is their MDM and/or time.

 

[Orthocoderpgu]

And why were your providers performing complete exams in the first place? Because they knew the more they documented, the higher the code they could bill. They were documenting more than what was medically necessary just to artificially inflate the code which is the entire reason for the 2021 guidelines. We want to get away from over documenting which was rampant to the extreme. As long as your providers understand that they are expected to document what's medically necessary for the ROS & Exam, your job is done.