![]() ![]() Although technically acceptable under 1995 guidelines, avoid charting only “normal” or “abnormal” under a system, instead list specific abnormal or pertinent normal findings.The * counts as a system/area in the 1997 guidelines. The bracketed red numbers are the bullets for the 1997 guidelines. The 10 listed items are for both the 19 guidelines. Psych: Awake, Alert, & Oriented (AAO) x3.MSK: Normocephalic/Atraumatic (NC/AT), Extremities w/o deformity or ttp.GI: Nontender/Nondistended (NTND), No hepatosplenomegaly (HSM).Clear to auscultation bilaterally (CTAB). Peripheral pulses 2+ and equal in all extremities. * Neck: Symmetric, trachea midline, No thyromegaly. ENMT: Atraumatic external nose and ears.Eyes: PERRL, no conjunctival injection, and symmetrical lids.Const: Well-nourished, Well-developed (WNWD), Young/Middle-Aged/Elderly Male/Female appearing stated age.Vital Signs: P / BP / RR / SpO2 / T I have reviewed the triage vital signs. Sample template for normal comprehensive physical exam In addition to reviewing all vitals as part of good patient care, include a statement in your documentation that the recorded vital signs were reviewed. With many EMRs, vital signs are usually automatically pulled into your note.The chief complaint will indicate certain positive or negative findings to be documented. Your examination is part of your decision making.If your department uses the 1997 guidelines, read through the bullets and pick 2 per system to include in your exam. Develop a structured, comprehensive exam that you can perform on nearly any patient, and use the normal findings for this exam as your documentation template.Work Smarter, Not Harder: Resuscitating the Physical Exam ** 1997 multi-system exam requires specific bullets for each system. * 1995 guidelines allow a combination of systems & body areas for PF, EPF, & Detailed exams. ![]() Don’t bother looking these up– in general, a comprehensive single organ system examination is more complicated to perform and document than a comprehensive multi-system exam. These guidelines also describe Single Organ System examinations, which focus on a primary organ system but require bullets from other systems. The full list of bullets is in the appendix at the end of this post. A comprehensive exam requires all bulleted items to be examined, and at least 2 per system to be documented. The 1997 guidelines define mandatory physical exam elements and called them Bullets. The 1995 guidelines identify Body Areas and Organ Systems as a framework for documenting the physical exam, but do not say what to chart under either. Overall, 1995 is too vague, 1997 is too specific, and the responsibility to choose one or the other falls on your coding department. There are 2 very different standards used to bill CMS and/or insurance companies: the 19 CMS guidelines. We are a crooked and perverse generation.” – Sir William Osler “There are no straight backs, no symmetrical faces, many wry noses, and no even legs. The following discussion tries to unravel some of these twisted regulations and will provide tips and tricks on how to improve your physical exam documentation for coding and billing. These disparities between what you do and how you’re asked to document it can lead to charts that are frequently down-coded or at risk if audited. Centers for Medicare and Medicaid Services (CMS), however, has physical exam guidelines for billing that conform to neither the exam you learned as a medical student nor the one you’ve refined as a resident. “What do I see, hear, and smell when I walk into the room?” While the oral boards challenge you to perform the physical exam in a certain way, the day to day examination of patients can vary dramatically. ![]() See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines. The new AMA CPT 2023 Documentation Guidelines have been published and the prior physical elements are no longer incorporated into the billing and coding guidelines. ![]()
0 Comments
Leave a Reply. |