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Thread: General Surgery template for E/M

  1. #1
    Join Date
    Apr 2007
    Dickson, TN

    Default General Surgery template for E/M

    AAPC: Back to School
    Does anyone have a template for General Surgery Evaluation and Management? How do they have a medically necessary 97 guideline visit?
    Debbie Potts England
    Lyles, TN 37098

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Template

    You are concerned about medical necessity. If you are planning to take someone to the OR there is a lot besides just the presenting problem that you need to take into account.

    I don't have a template but here are things to have your surgeons consider.

    For 99204 and 99205 you MUST have a comprehensive exam ... no way around it, you need 2 bullets for each of 9 systems.

    For 99203 you need a detailed exam ... 12 bullets from 2 or more systems

    Here are bullets that I would consider medically necessary for most general surgeons
    CONSTITUTIONAL - general appearance, 3 vital signs
    ENT - exam of oropharynx, inspection of lips, teeth, gums (if patient will be intubated for anesthesia it's medically necessary to examine these)
    RESPIRATORY - assessment of resp effort, auscultation of lungs
    CARDIOVASCULAR - auscultation of heart, examine extremities for edema
    LYMPHATIC - palpate lymph nodes in two areas (checking for infection)
    GI - Examine abdomen w/ notation of masses or tenderness, note presence/absence of hernia, or any other bullets necessary based on type of surgery required
    PSYCH - description of patient's judgment or insight, orientation x 3 (you want the patient to be capable of making an informed decision)
    (note - at this point you easily have a detailed exam)
    MUSCULOSKELETAL - Examine digits & nails for clubbing or cyanosis (good for everyone) - other bullets as appropriate for patient condition and surgery contemplated
    GU - as appropriate for gender and type of surgery
    CHEST - as appropriate for type of surgery
    SKIN - as appropriate for type of surgery
    NEURO - as appropriate for type of surgery

    If all your surgeons want to do is examine the actual hernia (as an example), then they will be limiting the coding to 99201. It's their choice.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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