PE from the door . . .

[Homunculus]

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so i had a discussion (jokingly) to a colleague today:

what is the most you can document without actually touching a patient?

awake, alert, no distress
normocephalic, clear conjunctiva, EOMI (if they are looking around) no rhinorrhea, no drooling, no ear drainage
no respiratory distress
normal gait (if they walk into the room)
no edema/cyanosis

any others?

we were wondering what CPT code you could ethically get if you accurately documented a "doorway" PE. . .

--your friendly neighborhood philosophizing caveman

 

[rotatores]

so i had a discussion (jokingly) to a colleague today:

what is the most you can document without actually touching a patient?

awake, alert, no distress
normocephalic, clear conjunctiva, EOMI (if they are looking around) no rhinorrhea, no drooling, no ear drainage
no respiratory distress
normal gait (if they walk into the room)
no edema/cyanosis

any others?

we were wondering what CPT code you could ethically get if you accurately documented a "doorway" PE. . .

--your friendly neighborhood philosophizing caveman

No retractions
No nasal flaring
Active and playful
Interactive

 

[IgD]

Alert and oriented x 3. Appropriately dressed and groomed. No psychomotor abnormalities. Eye contact good. Mood euthymic. Affect congruent. Speech normal rate, rhythm and tone. Thought process logical. No suicidal or homicidal ideation. No auditory or visual hallucinations. Memory and cognition grossly intact. Insight and judgment intact.

 

[NateintheED]

Not dying (at least acutely). No active external hemorrhage.

I was going to disagree with the last post based on title of the thread (PE from the door), but then read the OP's question specifies "without actually touching the patient". Probably wouldn't be able to get all those psych things just by looking from the door.

 

[TheGoose]

Not dying (at least acutely). No active external hemorrhage.

I was going to disagree with the last post based on title of the thread (PE from the door), but then read the OP's question specifies "without actually touching the patient". Probably wouldn't be able to get all those psych things just by looking from the door.

hahaha. this one made me laugh out loud.

 

[Mirror Form]

Don't forget about PERRL, although you couldn't actually do that from the door.

 

[The White Coat Investor]

You can also document that you reviewed everything the nurse, student, and resident did.

 

[DD214_DOC]

Apparently you can do an entire PE when, in reality, doing nothing and then yelling at a lowly 2LT/MS4 for leaving most of the admit note blank and not falsifying information. That was the day I decided to not apply for that program.

 

[Arcan57]

Neck supple (unless they're in a c-collar or halo), no visible skin lesions, nl gait (if you saw them walk in).

 

[orbitsurgMD]

Don't forget about PERRL, although you couldn't actually do that from the door.

Tongue in cheek, I hope.

 

[Doctor Bob]

Don't forget about PERRL, although you couldn't actually do that from the door.

Sure you can. Flip the light switch on and off quickly. That ought to be close to the doorway you're standing in.

 

[rotatores]

Sure you can. Flip the light switch on and off quickly. That ought to be close to the doorway you're standing in.

👍

 

[BigNavyPedsGuy]

Don't forget the ">50% of time spent counseling and coordinating care" checkbox

 

[backrow]

Don't forget the ">50% of time spent counseling and coordinating care" checkbox

That's the best box in AHLTA.

I always like it when the coders come and tell me to stop checking that box. I then tell them that I'll be more than happy to fwd my notes to them for coding and they quickly find a way to the exit for some reason.

 

[AF M4]

That's the best box in AHLTA.

I always like it when the coders come and tell me to stop checking that box. I then tell them that I'll be more than happy to fwd my notes to them for coding and they quickly find a way to the exit for some reason.

You have to admire the twisted genius of the coders however. Here you have a field that was literally created out of the ether in the past decade or so and has somehow already gotten itself considered indispensable to the medical field so much so that every clinic has to have a dedicated coder just to function. Plus they all have like 20 letters trailing behind their name like "Mary Smith, RHIA, CCS, CCS-P", and no one has the slightest idea of what they mean and no one wants to question it because we don't like talking to them in general. They have their own academy, and every year we have to buy the new version of their inscrutable "codebook", or else the government won't reimburse clinicians for treatments rendered.

It's a brilliant conspiracy I tell you, and it's doubly clever because everyone just sort of accepts it. We are all of us slaves to the ICD-9.

 

[DD214_DOC]

You have to admire the twisted genius of the coders however. Here you have a field that was literally created out of the ether in the past decade or so and has somehow already gotten itself considered indispensable to the medical field so much so that every clinic has to have a dedicated coder just to function. Plus they all have like 20 letters trailing behind their name like "Mary Smith, RHIA, CCS, CCS-P", and no one has the slightest idea of what they mean and no one wants to question it because we don't like talking to them in general. They have their own academy, and every year we have to buy the new version of their inscrutable "codebook", or else the government won't reimburse clinicians for treatments rendered.

It's a brilliant conspiracy I tell you, and it's doubly clever because everyone just sort of accepts it. We are all of us slaves to the ICD-9.

I did rotate through one very large primary care clinic with a kickass EMR program. This program would automatically generate all of the ICD-9 codes for the visit as well as the visit level based upon the stuff checked during the encounter. You clicked to end the encounter after leaving the room and a pre-completed super bill was printed at the checkout desk. Genius.

So, I'm not really sure why offices keep these people around. Maybe they can work their voodoo magic to get stuff reimbursed that otherwise shouldn't be? I'm not really sure.

 

[Homunculus]

That's the best box in AHLTA.

I always like it when the coders come and tell me to stop checking that box. I then tell them that I'll be more than happy to fwd my notes to them for coding and they quickly find a way to the exit for some reason.

i was told once by an attending you're only supposed to click that thing like half the time, or it can be considered "fraud". 🙄

my latest fave is the -25 modifier for additional stuff parents of my patients complain about. ie, the "well baby" with some rash, ear infx, eye thing, blah blah blah. it supposedly gives us credit/RVU's for that stuff. throwing on a little dry skin and eucerin = RVU magic!

right now i basically churn out all 99214's using dragon and the -25 modifier not sure where i sit for my average, but i can't do much more . . .

--your friendly neighborhood RVU generator caveman