Minimal Physical Exam in follow up notes

[Timeoutofmind]

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Question:

I am basically wondering if it is a problem to not examine the patient during follow up office visits specifically in terms of billing. I find it doesnt add anything a lot of the time and really slows me down. I have been doing it less and unless I have some specific thing I am looking for in terms of changes.

What I mean is, for billing purposes, on follow up visits, only 2 of 3 of the History/PE/Decision making must be met or exceeded

My History and Physical Exam on any follow up almost always meet Level 4. The reason is the my HPI is copied forward with modifications and my exam is as follows:

Vital Signs
General: Alert and oriented to person
Affect: No apparent distress
Head: normocephalic, atraumatic
Neck: No gross asymmetry noted, no masses noted
Eyes: anicteric; no injection
Ears/Nose: No notable scar/lesions/masses
Respiratory: breathing comfortably

Which meets a detailed exam according to 1995 guidelines.

I guess my question is
1. Is this minimal exam a problem billing-wise?
2. Is this an unwise thing to do medico-legally? For instance, if it is an ESI f/u...and there is a delayed complication of some sort, and I did not examine the patient seems like I would be on the hook. My rationale for not doing an exam is that they would let me know if they had new weakness/numbness/incontinence during the post op f/u phone calls.

Thanks in advance

 

[Aether2000]

Most people do minimal exams that meet the E&M criteria or you may still bill by time for consultation with the patient without having any specific physical exam criteria. For blocks, a simple statement such as no change in neuro status combined with a brief neurophysical exam such as "numbness in left S-1 dermatome with pos SLR" may keep you out of harms way.

 

[deleted185747]

If your question is strictly about billing and coding then ask that type of expert. If your question is medico legal then I am happy to help:
-referring physicians/peer reviewers/insurance physicians will spot the BS in your physical examination if its minimal.
-FBI/DOJ/DEA views this as no physical exam was performed if they are trying to nail you for medicare fraud / opioid over prescribing (they are lumping these together now). Some states require a history and physical examination as necessary prior to prescribing opioids.
-Insurance companies may start using physical examination requirements to force physicians to do more and slow down the flow of patients through the office and decrease spending. I met a guy who has numerous "standard" physical exam findings for various conditions and would randomly select one of these so that sequential notes have different physical examinations.
-I've seen physicians disciplined for excessive steroid injections when physical examination revealed pitting edema at ankles and plan for repeat injection was made. (Medical board then decided 4-6 steroid injections in a 12 month period is within standard of care and this doc was more than that)

 

[Ligament]

If your question is strictly about billing and coding then ask that type of expert. If your question is medico legal then I am happy to help:
-referring physicians/peer reviewers/insurance physicians will spot the BS in your physical examination if its minimal.
-FBI/DOJ/DEA views this as no physical exam was performed if they are trying to nail you for medicare fraud / opioid over prescribing (they are lumping these together now). Some states require a history and physical examination as necessary prior to prescribing opioids.
-Insurance companies may start using physical examination requirements to force physicians to do more and slow down the flow of patients through the office and decrease spending. I met a guy who has numerous "standard" physical exam findings for various conditions and would randomly select one of these so that sequential notes have different physical examinations.
-I've seen physicians disciplined for excessive steroid injections when physical examination revealed pitting edema at ankles and plan for repeat injection was made. (Medical board then decided 4-6 steroid injections in a 12 month period is within standard of care and this doc was more than that)

Plan; opt out of Medicare

 

[Timeoutofmind]

Thanks for the advice

F/u question

What is the minimal Physical exam reasonable for a quick pre-injection H&P if pt has not been seen within 30 days?

Again...if I put in the exam I posted above is that going to be a problem? Is that what you guys do? Or do you actually do some MSK exam and document. Just seems so unnecessary like 90% of the time.

 

[hyperalgesia]

Thanks for the advice

F/u question

What is the minimal Physical exam reasonable for a quick pre-injection H&P if pt has not been seen within 30 days?

Again...if I put in the exam I posted above is that going to be a problem? Is that what you guys do? Or do you actually do some MSK exam and document. Just seems so unnecessary like 90% of the time.

This is "pay to play" for joint commission accredidation. My facilities require heart and lung exam or they won't let me do my hip injection.

 

[myrandom2003]

so my understanding is, for follow ups you 2 of the three components to figure out billing level.
i try to get my points on history and medical decision making (which includes managing prescription meds)
I think the audits happen the most with the exam

 

[clubdeac]

I just bill based on time for a lot of these 15 min for a level 3 and 25 min for a level 4. I have a hard time accepting that that physical exam would meet the requirements for a level 4 (detailed e/m note). Does it really?

 

[Timeoutofmind]

I just bill based on time for a lot of these 15 min for a level 3 and 25 min for a level 4. I have a hard time accepting that that physical exam would meet the requirements for a level 4 (detailed e/m note). Does it really?

Yeah according to 1995 examination guidelines which r still ok to use is my understanding.

5-7 organ systems is a level 4 exam