Visual / Observation Physical Exam Template

[thegenius]

Do you guys have a physical exam macro/template you use that satifies CPT 99285 that can be done by just looking at a patient? And maybe examining the one thing they complain of like wrist pain or a rash or whatever.

For instance:
Gen: no distress, well kept, alert
Head: atraumatic, normocephalic
ENT: appropriate conjugate gaze, no scleral icterus, EOMI, no nasal discharge, no stridor, no drooling
blah
blah
blah

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[southerndoc]

If you see them for wrist pain and document as a 99285, that doesn't mean you can bill as a 99285. A simple wrist pain (i.e., a strain) at most will get you a 99284. Anything more puts you at risk of audit and fraud charges unless it's high risk (arterial occlusion, arterial injury, paralysis, etc.).

 

[deleted547339]

Yes. I have a brief physical exam from the door.

 

[BoardingDoc]

If you see them for wrist pain and document as a 99285, that doesn't mean you can bill as a 99285. A simple wrist pain (i.e., a strain) at most will get you a 99284. Anything more puts you at risk of audit and fraud charges unless it's high risk (arterial occlusion, arterial injury, paralysis, etc.).

I suspect the question is how to write a template for every patient to satisfy the 8 PE findings required for a lvl 5 chart so that if your coders mark it as a lvl 5 you actually qualify for it. I don't think OP is suggesting that every trivial visit be coded as a lvl 5 chart.

I do this for every patient .The coders can make it whatever level they want, but this way I never run into an issue where they mark it as a 5 but I have only 6 exam findings or only 9 ROS and it turns into a 4.

 

[thegenius]

I suspect the question is how to write a template for every patient to satisfy the 8 PE findings required for a lvl 5 chart so that if your coders mark it as a lvl 5 you actually qualify for it. I don't think OP is suggesting that every trivial visit be coded as a lvl 5 chart.

I do this for every patient .The coders can make it whatever level they want, but this way I never run into an issue where they mark it as a 5 but I have only 6 exam findings or only 9 ROS and it turns into a 4.

Yes that is what I meant! I should have further clarified that. And no, I'm not into causing fraud. I don't want to lie.

Can anyone post examples?

I looked into this before...and I think CMS (or Medicare or whomever) will only allow for certain physical exam findings in each organ system. Not every entry into the "Heart" field will count.

For instance, can one say "no rash on the face and hands" for the skin organ system? would that be satisfactory as an exam finding under an audit?

 

[southerndoc]

There's really no way to document a cardiovascular system without listening to a person's heart, documenting pulses, or documenting CRT.

I have a habit of listening to EVERY PATIENT'S lungs and heart. It doesn't matter if they're there for a toothache, finger laceration, or whatever, they get a heart and lung exam.

 

[BoardingDoc]

There's really no way to document a cardiovascular system without listening to a person's heart, documenting pulses, or documenting CRT.

I have a habit of listening to EVERY PATIENT'S lungs and heart. It doesn't matter if they're there for a toothache, finger laceration, or whatever, they get a heart and lung exam.

I just skip CV in most patients and make up for it elsewhere in things like HEENT (NCAT), lungs (no resp distress) etc etc

 

[CajunMedic]

Let me see if I can recreate mine without remoting in to the EHR and looking at it:

All of ours are written to a Level 5 standard.

Skin: No rashes, no jaundice, no lesions, no petechiae
Head: NC/AT
Eyes: EOMI, 0 Icterus, vision grossly intact
Neck: Trachea Midline, 0 JVD
Chest: CEBBS, Equal Expansion
Cardiac: No Edema, RRR
Abd: Non-Tender, Normoactive Bowel Sounds (I listen and palpate everyones along with heart and lungs)
Back: Midline, No Stepoffs, No CVAT (maybe 10-15 seconds to walk my fingers down their spine)
Psych: Normal Affect, Normal Speech, Non-suicidal

 

[southerndoc]

Be careful with "no rashes or lesions." I would add "on exposed areas." I know of one doc (albeit primary care) who was sued for documenting no rashes or lesions. Guy ended up with melanoma and sued her. Didn't win, but patient's point was the doc documented she examined him but in actually she didn't.

Are you watching their eye movements enough to track their every move to see if EOM are intact? Simply documenting "no scleral icterus or discharge" is enough to qualify for the organ system.

JVD truly can't be measured unless at a 45 degree angle. Maybe "Tracheal midline, no stridor" is enough to qualify.

--
Constitutional: No acute distress. Vital signs reviewed.
Head: Normocephalic without overt signs of trauma.
Eyes: No scleral icterus or discharge.
Ears: External ears are atraumatic. No Frank sign seen.
Neck: No stridor or tracheal deviation.
Throat: Lips do not appear parched.
Cardiac: Regular rate and rhythm without murmur.
Pulmonary: Clear to auscultation bilaterally.
Gastrointestinal: Abdomen does not appear distended.
Musculoskeletal: No obvious deformities on exposed limbs identified. Ambulatory.
Neurologic: Alert and oriented. Moves all extremities without difficulty.
Skin: No rashes identified on exposed skin. Not diaphoretic.
Psych: Does not appear confused. Normal affect.

That will qualify for the physical exam portion of a 99285 if you just put the stethoscope to their chest. You don't even have to listen to their back. Just the front. Patients always think you take more time with them if you pull out your stethoscope. It's what they associate with a doctor.

I pretty much have this in all my "basic" templates. I never get to a 99285 on simple stuff because I don't ask all the review of system questions.

 

[BoardingDoc]

I never get to a 99285 on simple stuff because I don't ask all the review of system questions.

Any fever, pain, swelling or cough? That gets you 10.

 

[southerndoc]

Any fever, pain, swelling or cough? That gets you 10.

How can 4 questions get you to 10? Are you using "pain" to refer to chest pain, headache, abdominal pain, earache, back pain, flank pain, etc.?

 

[BoardingDoc]

How can 4 questions get you to 10? Are you using "pain" to refer to chest pain, headache, abdominal pain, earache, back pain, flank pain, etc.?

yes.

EDIT: Similar (and in my case identical) to the discussion and here: History and Physical limited because...