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To give a bullet, or not to give a bullet...

  1. #1
    Question To give a bullet, or not to give a bullet...
    Medical Coding Books
    That is the question...

    I've got some new ones to get everyone's thoughts on...Some I know, but some I'm not sure about, so I'll just copy all of them...I'm only interested in where you'd credit on 1997 guidelines, please - (I can't score it on 1995 due to our protocol.)

    CC: Cough, SOB (COPD)

    General: Awake. Alert. Appropriate.
    Head: No sign of injury
    (<---I thought this one was odd)
    Ears: No TM erythema, No edema. Landmarks clear.
    Oropharynx: No erythema. No exudate.
    Neck: Supple. No adenopathy, full ROM
    Respiratory: Lungs CTA, respirations non-labored, breath sounds are equal. Symmetrical chest wall expansion. No chest wall tenderness
    Cardiovascular: Regular rate and rhythm
    GI: Soft. Bowel sounds active. Non-distended. Non-tender. No guarding, rigidity, distention or tenderness.
    (A little redundant...)
    Neurological: CN II-XII intact
    Integumentary: Warm Dry Pink & Intact
    Psychological: AOx4


    I've got bullets for:
    2 Constitutional (vitals are also documented)
    2 ENT: (otoscopic exam of TM, exam of oropharynx)
    1 Neck: exam of neck
    2 Resp: Ascultation of lungs, assessment of resp. effort
    1 CV: ascultation of heart
    2 GI: exam of abdomen, exam of liver/spleen (I count for 'no distention')
    2 Musculoskeletal (neck, spine/ribs/pelvis): inspection and/or palpation w/notation of tenderness
    1 neuro: Test Cranial nerves
    1 psych: orientation to time, place, person

    The things I'm unsure of are:
    "Appropriate" - enough to count for psych, mood and affect?
    "Landmarks clear" - I've never seen that before...
    "No sign of injury" - that just seems so random...does it count for anything?
    Are there any others that I might have missed? I'd like to make the provider's education as accurate as possible, so I want to give credit everywhere it's due...please let me know what you think!

  2. #2
    Location
    Ellenville, New York
    Posts
    1,177
    Default My 2 cents
    Quote Originally Posted by btadlock1 View Post
    That is the question...

    I've got some new ones to get everyone's thoughts on...Some I know, but some I'm not sure about, so I'll just copy all of them...I'm only interested in where you'd credit on 1997 guidelines, please - (I can't score it on 1995 due to our protocol.)

    CC: Cough, SOB (COPD)

    General: Awake. Alert. Appropriate.
    Head: No sign of injury
    (<---I thought this one was odd)
    Ears: No TM erythema, No edema. Landmarks clear.
    Oropharynx: No erythema. No exudate.
    Neck: Supple. No adenopathy, full ROM
    Respiratory: Lungs CTA, respirations non-labored, breath sounds are equal. Symmetrical chest wall expansion. No chest wall tenderness
    Cardiovascular: Regular rate and rhythm
    GI: Soft. Bowel sounds active. Non-distended. Non-tender. No guarding, rigidity, distention or tenderness.
    (A little redundant...)
    Neurological: CN II-XII intact
    Integumentary: Warm Dry Pink & Intact
    Psychological: AOx4


    I've got bullets for:
    2 Constitutional (vitals are also documented)
    2 ENT: (otoscopic exam of TM, exam of oropharynx)
    1 Neck: exam of neck
    2 Resp: Ascultation of lungs, assessment of resp. effort
    1 CV: ascultation of heart
    2 GI: exam of abdomen, exam of liver/spleen (I count for 'no distention')
    2 Musculoskeletal (neck, spine/ribs/pelvis): inspection and/or palpation w/notation of tenderness
    1 neuro: Test Cranial nerves
    1 psych: orientation to time, place, person

    The things I'm unsure of are:
    "Appropriate" - enough to count for psych, mood and affect?
    "Landmarks clear" - I've never seen that before...
    "No sign of injury" - that just seems so random...does it count for anything?
    Are there any others that I might have missed? I'd like to make the provider's education as accurate as possible, so I want to give credit everywhere it's due...please let me know what you think!
    Brandi: on your three question marks, here is my feedback:

    "Appropriate" - I do not count that for psych unless specificallly documented. Appropriate what? (I may be too conservative, but I never have had a complaint!)

    "Landmarks clear" - Landmarks for an ear exam usually involve any items of note that can be observed on the external ear, auditory canal, and/or TM. In this case, I would request clarificaion if the "landmarks" are an extention of the TM exam or if these refered to the external ear, in which you may give another. But if this is part of the canal/TM exam, no, I would not give another bullet.

    "No sign of injury" - here I would give credit, as I interpret this as another way of documenting a normal exam.

    Don't you LOVE these grey areas? When 1997 really is supposed to be more clear cut, right?

    Anyway, that is one man's opinion, and you know what they say about opinions....

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default "No distension"
    ONLY listing those areas where I differ from your assessment.

    I would NOT count "no distension" as exam of liver and spleen. The abdomen can be distended for a large variety of reasons. I'd expect to see "no hepatosplenomegaly" to get this bullet.

    "no sign of injury" .... the musculoskeletal bullet requires examination of "head AND neck" .... so no additional bullet for this. It DOES count towards your one MS bullet for head and neck.

    Respiratory - I'm not sure I would count "symmetrical chest wall expansion" as a measure of respiratory effort. However I would count "no chest wall tenderness" as bullet for "palpation of chest.

    Integumentary - 1 bullet for inspection of skin.

    So I get
    Constitutional ............ 2 bullets (taking your word on vitals)
    Eyes ......................... 0
    ENT .......................... 2
    Neck ......................... 0 (I'm using this in musculoskeletal in conjunction w/ head)
    Respiratory................. 2
    CV............................. 1
    Chest ........................ 0
    GI.............................. 1
    GU............................. 0
    Lymphatic................... 0 (he did mention no adenopathy in neck, but you need TWO areas to get one bullet)
    Musculoskeletal............1 (head and neck)
    Skin............................1
    Neurologic...................1
    Psychiatric...................0

    11 bullets = EPF exam

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Default
    Quote Originally Posted by FTessaBartels View Post
    ONLY listing those areas where I differ from your assessment.

    I would NOT count "no distension" as exam of liver and spleen. The abdomen can be distended for a large variety of reasons. I'd expect to see "no hepatosplenomegaly" to get this bullet.

    "no sign of injury" .... the musculoskeletal bullet requires examination of "head AND neck" .... so no additional bullet for this. It DOES count towards your one MS bullet for head and neck.

    Respiratory - I'm not sure I would count "symmetrical chest wall expansion" as a measure of respiratory effort. However I would count "no chest wall tenderness" as bullet for "palpation of chest.

    Integumentary - 1 bullet for inspection of skin.

    So I get
    Constitutional ............ 2 bullets (taking your word on vitals)
    Eyes ......................... 0
    ENT .......................... 2
    Neck ......................... 0 (I'm using this in musculoskeletal in conjunction w/ head)
    Respiratory................. 2
    CV............................. 1
    Chest ........................ 0
    GI.............................. 1
    GU............................. 0
    Lymphatic................... 0 (he did mention no adenopathy in neck, but you need TWO areas to get one bullet)
    Musculoskeletal............1 (head and neck)
    Skin............................1
    Neurologic...................1
    Psychiatric...................0

    11 bullets = EPF exam

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Yes, I only count that for consistency's sake, on the first audit I do for each provider. Our EMR has that in the prompts, and they haven't been educated on the guidelines when I audit them, usually. I do inform them that I'm not really comfortable assigning credit for it, and that at minimum, I will expect to see 'no organomegaly' accompanying it, for future credit. It doesn't usually make or break the code selection, for most notes...

    I count 1 Neck bullet for "supple", since that seems like an examination of the neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)

    I decided against counting the 'no sign of injury' for 2 reasons:
    1) it was totally irrelevant to the chief complaint, and I found it on several notes - it's like it's just there to take up space. Trailblazer makes it pretty clear that they wouldn't have counted it, under those circumstances, in the publication I referenced for the doctor.
    2) I consider a 'sign of injury' to be open to interpretation, and wouldn't necessarily always quantify it as Musculoskeletal, although I do see the bullet you're talking about...My thinking on it is, a busted lip or black eye could both reasonably be signs of injury, and they don't really fall under M/S - also, there could be signs of a concussion that could appear in the eyes...I guess I just have a broad definition of the word "injury", really...

    For the respiratory, the 'symmetrical chest wall expansion' isn't as much of the respiratory effort-assessment as the phrase "respirations non-labored", for me, although they both fit under the same general bullet.

    I also give 2 bullets for Skin, which I forgot to put earlier:
    Inspection: Pink & Intact
    Palpation: Warm, dry

  5. #5
    Default My take on your senario
    Brandy,
    When I initially began E&M coding I used 1997 exclusively, I have the bullets memorized.
    So……Here is my audit of what you wrote: 15 Bullets, which would be a detailed exam
    CONSTITUTIONAL
    o Vitals
    o General appearance – awake/alert
    PSYCH
    o Orientation – A & O X4
    ENMT
    o External inspection of ears & nose – landmarks clear
    o Otoscopic exam – No TM erythema
    o Exam of oropharynx – No erythema
    NECK
    o Exam of neck – Supple
    RESPIRATORY
    o Respiratory effort – non labored
    o Auscultation of lungs – CTA
    CARDIOVASCULAR
    o Auscultation of heart
    GI
    o Exam of abdomen – soft, non distended
    MUSCULOSKELETAL
    o Assessment of ROM – Head & Neck
    SKIN
    o Inspection of skin – pink and intact
    o Palpation of skin – warm and dry
    NEUROLOGIC
    o Test cranial nerves – CN II-XII
    I would not get the exam of liver and spleen, I look for “no organomegaly” or “no hepatosplenomegaly” to give credit for that.
    I personally prefer the 97 exam because even though there are still “grey” area's, I still believe it is more cut and dry than 95 guidelines!
    Last edited by MandyFlagg; 10-27-2011 at 05:48 AM. Reason: notification
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

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