# Level 4 Office Visits



## mkees (Mar 16, 2009)

We are an Orthopedic speciality office and I am wondering if any one in the same speciality is getting level 4 office visits and how.  We are not, mostly because of the exam..per the guidelines for the musculoskeletal exam the dr has to perform all systems and all elements, so if anyone is getting the level 4, are your docs doing the complete exam?? Am I missing something?

Thanks!


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## LLovett (Mar 16, 2009)

I don't currently have any ortho providers but when I did they never met the guidelines for a comprehensive exam. I am assuming you are talking about the new and consults. 

It was always very frustrating to them and me since many of those elements of exam are not medically necessary in a lot of ortho exams. On the other hand, they weren't the best documenters either. 

Do any of your providers spend a lot of time with the patients? That would be one way they may qualify for a 4, if they document time properly.

Good luck,

Laura, CPC


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## FTessaBartels (Mar 16, 2009)

*1997  vs 1995*

HISTORY:  You should have a patient questionaire that covers all 14 systems, past medical, family and social history.  The patient completes this while in the waiting room. The physician reviews, signs and dates it, and then in the patient progress note for that date states any *pertinent *(positive or negative) and adds "For complete ROS, PFMSH please see the patient questionaire dated dd/mm/yy, reviewed by myself today."

EXAM:  Have you considered looking at the 1995 guidelines? For a comprehensive exam you need to cover 8 or more of the 12 organ systems outlines in 1995 guidelines:
Constitutional (Vitals, general appearance)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunological

Your office may be using 1997 guidelines most of the time, but it never hurts to double check a note using the 1995 guidelines. 

I know it is really difficult to get to the comprehensive exam for most Ortho specialists. 

Laura's suggestion that they consider documenting face-to-face time is good, but ONLY if >50% of the time is spent in counseling/coordination of care. 

Good luck. I hope that helps.

F Tessa Bartels, CPC, CEMC


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## RebeccaWoodward* (Mar 17, 2009)

I, too, often find that the exam is the culprit for new patients/consults.  Often their exam is limited to a particular area; especially for my hand surgeon. However, there are occassions when it is medically necessary to have a comprehensive exam for my other orthopods.  It really depends on the medical condition or the traumatic event.


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## mkees (Mar 17, 2009)

Yes, this is for new patient and consults.  I have one doctor doing trauma and the resident is dictating...so for those I struggle to get a level 3 mainly because of the ROS and exam.  Otherwise, you all have hit the nail on the head.  Thanks!


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## Travelgirl (May 12, 2009)

Has anyone tried to a single comprehensive system examination?  I have an a Family Medicine doc who primarily does sport managment patients.   He only does the musculoskeletal exam, he's been talking to one of my Cardiology providers who is trying to also document for a single organ exam under 1995 (put a question in the E/M forum as well).  I've been looking at this but I'm not sure myself.

He reviews gait, range of motion in the affected area and compares it to the none affected area.  Misalignment and tenderness is noted as well as strength.   I don't think that this meets the requirement.   He is unable to get a higher level of service than 3 for new or consult visits either.   He doesn't remember to document the time spent Counseling and Coordination of Care either.


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## CrysLednum (May 13, 2009)

I also work for an ortho specialty group and while we would like to have many level 4's, the unfortunate fact is that the consultations seem to be History driven.  

I just attended the Advance E/M workshop from Highmark and we are using their audit sheets to check the docs and we are finding that if we don't have a complete PFSH, ROS and extended HPI we will never have a level 4 or 5 consultation code.   (Although if time was documented I should never say never, but our docs do not indicate time in a lot of the consults.) 

My interpretation is that the physician will have to really take the time & document when doing the history portion rather than just doing a problem-focused history.


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