# Components of extremity PE



## trinalankford (May 8, 2015)

I have a physician who will document vital signs (constitutional) and then an extremity exam but absolutely nothing else, as follows:

*There is a puncture wound in the plantar heel, surrounding soft tissue swelling, but no erythema, drainage, or purulence. Ankle is normal to inspection, nontender, normal ROM. Leg is uninjured above the ankle. Gait not tested due to pain. Neuro: Sensation is normal. Vascular: No vascular compromise. Skin: Warm, dry, intact.*

We are having trouble coming to a consensus in our office. Some say the neuro, vascular, and skin should be counted separately, so Detailed PE. Some say they are components of the extremity exam, since the descriptions above pertain specifically to the extremities only, i.e., no cranial nerve exam, etc., so Prob Focused PE (single BA).

Thoughts?  Thank you!


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## BenCrocker (May 8, 2015)

Looks Focussed around the Ankle, foot and leg area just 
Proximal to the injury to me. But that's just my opinion.


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## trinalankford (May 8, 2015)

BenCrocker said:


> Looks Focussed around the Ankle, foot and leg area just
> Proximal to the injury to me. But that's just my opinion.



So you're not counting the neuro, vascular, and skin as three additional OS, just inclusive in the extremity exam?


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## BenCrocker (May 9, 2015)

I'm no Dr. And I'm only an apprentice so I really am not the most wise in my OPINION.


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## LLovett (May 11, 2015)

I would count the organ systems not the body areas. As long as your carrier doesn't require the 4x4 exam in 95 for detailed, I would agree with detailed at 5 organ systems.

I only count body areas if the info is to generic to attribute to a specific organ system. Clearly this is specific enough to support the individual systems. To me an exam of the body area for extremity would be very generic, something like "right leg normal".

That's my take on it,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC


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## trinalankford (May 11, 2015)

Laura: Thanks for your reply. In counting five OS, you're counting Constitutional, MSK, Neuro, Vascular, and Skin? Just want to make sure I'm understanding correctly.

I do value everyone's opinion, especially when it comes to E&M because everyone interprets things so differently.


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## mitchellde (May 11, 2015)

I disagree with detailed under the 95 guidelines.. It states an extended exam of the affected area and symptomatic or related body areas.  I am not seeing an extended exam of the affected area nor don't see 5 separate symptomatic systems or areas.  I think expanded focused at best.


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## LLovett (May 11, 2015)

Yes, I counted Constitutional, MS, Neuro, CV, and Skin. 

I guess we will have to agree to disagree Debra. Unless otherwise specified, as in the case of the 4x4, I allow for 5-7 organ systems to meet detailed under 95 based on my experience with multiple carriers over the years.

Laura, CPC, CPMA, CPC-I, CANPC, CEMC


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## mitchellde (May 11, 2015)

LLovett said:


> Yes, I counted Constitutional, MS, Neuro, CV, and Skin.
> 
> I guess we will have to agree to disagree Debra. Unless otherwise specified, as in the case of the 4x4, I allow for 5-7 organ systems to meet detailed under 95 based on my experience with multiple carriers over the years.
> 
> Laura, CPC, CPMA, CPC-I, CANPC, CEMC



I get it, I am just way more conservative in my approach, and I keep in mind the medical necessity as that is CMS most primary concern with regard to the level of care.  So unless there is more to the story, a puncture wound of the heel does not support a detailed exam.  Which is why I look at this as a limited exam of the affected area.


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## trinalankford (May 11, 2015)

mitchellde said:


> I disagree with detailed under the 95 guidelines.. It states an extended exam of the affected area and symptomatic or related body areas.  I am not seeing an extended exam of the affected area nor don't see 5 separate symptomatic systems or areas.  I think expanded focused at best.



This was my thought, actually maybe even problem focused because he only did constitutional (VS) plus the extremity exam which would be 1 BA/OS plus 1 OS which doesn't even equal EPF (1 BA/OS plus 2-7 OS).  

I was having difficulty expressing that in words to my co-workers to even open up a helpful discussion. They have been using it as Detailed exam, for reasons stated by Laura, but I'm not seeing how the Vascular, Neuro, and Skin could be considered their own exams when they are obviously pertaining only to the extremities.

Is there a more definitive guide out there to the E&M rules? I have the CMS official rules, which are vague at best, and I've even looked at the Ingenix E&M Coding Advisor, but I'm finding E&M so incredibly vague (and sometimes discrepant). There *has* to be a better reference out there somewhere.

Thank you all for your time on this!


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## trinalankford (May 11, 2015)

mitchellde said:


> I get it, I am just way more conservative in my approach, and I keep in mind the medical necessity as that is CMS most primary concern with regard to the level of care.  So unless there is more to the story, a puncture wound of the heel does not support a detailed exam.  Which is why I look at this as a limited exam of the affected area.



I *really* prefer the cases where the E&M level has been determined without the use of the PE, especially when there is such a gray area like this, but sometimes this is actually the deciding factor in the overall E&M...as you all know.  This one did come down to the PE part of the equation, which is why I finally presented my question.


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## mitchellde (May 11, 2015)

This is where you must look at the entire scenario.  Like I said CMS has stated that the primary determining factor in the visit level is the medical necessity.  This is a puncture wound.  So what is there to this story that can support say a level 4 visit since I assume that is what you are trying to achieve.  It TRUELY does not look like a level 4 unless there is more that has not been posted.  Also to exam the puncture site and look for redness and drainage is the minimum that must be performed, what else about the exam of the affected areas makes this a detailed exam?  I see nothing in what you have stTed that is beyond the basics.  There is no mention of a foreign body still present, the degree of pain, or anything thing else, so if you are trying to "push" this to a level 4 visit, then my advice is to go with a level3 as that I can see as supported by the medical necessity and the document.


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## trinalankford (May 11, 2015)

mitchellde said:


> This is where you must look at the entire scenario.  Like I said CMS has stated that the primary determining factor in the visit level is the medical necessity.  This is a puncture wound.  So what is there to this story that can support say a level 4 visit since I assume that is what you are trying to achieve.  It TRUELY does not look like a level 4 unless there is more that has not been posted.  Also to exam the puncture site and look for redness and drainage is the minimum that must be performed, what else about the exam of the affected areas makes this a detailed exam?  I see nothing in what you have stTed that is beyond the basics.  There is no mention of a foreign body still present, the degree of pain, or anything thing else, so if you are trying to "push" this to a level 4 visit, then my advice is to go with a level3 as that I can see as supported by the medical necessity and the document.



I agree. I may not have stated it correctly, but I am not trying to push it to a level 4. I don't believe the neuro, vascular, and skin should count as separate entities. I was attempting to find justification somewhere else that supports my opinion. Coming in as the "new guy" and questioning others has been difficult. I simply needed some validation, I guess, and you worded it a lot more eloquently than I could. I'm even having trouble justifying EPF because he doesn't have a second OS (1+2), only the 1+1 (VS plus ext) which is the PF...although the medical necessity here, I believe, is more in line with a higher level than level 1 (PF).


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## mitchellde (May 11, 2015)

I agree with your assessment of the scenario.  I think you have looked at it objectively and have come to the correct answer.


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## LLovett (May 11, 2015)

Without the rest of the note it is impossible to determine medical necessity, one way or the other. As it stands, I see 5 organ systems, which regardless of the rest of the note or medical necessity, can support a detailed level of exam. 

Supporting a level and billing for a level are 2 completely separate issues. Unless the rest of the note is posted and the question of what overall level of service can be billed is asked, we can only address the first issue.

As to the comment about pain not being mentioned, it is implied that the pain was so severe the patient can't walk. I'm also curious about the comment regarding the minimum exam. I'm not aware of any recognized minimum standards that have to be met before you could consider an exam a certain level.

This is an interesting topic, a nice distraction from the chaos in my day!

Laura, CPC, CPMA, CPC-I, CANPC, CEMC


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## dclark7 (May 11, 2015)

While I agree that this does not meet the criteria for a detailed exam, I'm having trouble understanding your reasoning for only problem focused and not EPF.  According to the E/M Documentation Guidelines a Problem Focused exam is "a limited examination of the affected body area *or* organ system.  An Expanded Problem Focused exam is "A limited examination of the affected body area *or* organ system and other symptomatic or related organ systems.

 If you look at this exam as body area then you have one plus the VS which still meets the requirements for EPF.  If you look at organ systems you have Const (VS), M/S (Ankle ROM, leg uninjured above ankle), Skin (puncture wound, warm, dry, intact), Neuro (sensation normal) and C/V.  As both Debra and Laura stated without the rest of the note you can't determine medical necessity, but I would have coded the exam itself as EPF.


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## trinalankford (May 11, 2015)

LLovett said:


> Without the rest of the note it is impossible to determine medical necessity, one way or the other...Unless the rest of the note is posted and the question of what overall level of service can be billed is asked, we can only address the first issue.
> 
> As to the comment about pain not being mentioned, it is implied that the pain was so severe the patient can't walk. I'm also curious about the comment regarding the minimum exam. I'm not aware of any recognized minimum standards that have to be met before you could consider an exam a certain level.
> 
> ...



I am not able at this time to post the remainder of the note, and I apologize for that. I know that limits the feedback I can receive.

As far as "pain not being mentioned," I'm confused by this. I'm not sure where in the thread this is mentioned?

I'm also confused as to "not aware of any recognized minimum standards that have to be met...."  I must be getting rummy this late in the day 

I'm glad I could distract you for an interesting conversation 



dclark7 said:


> ....I'm having trouble understanding your reasoning for only problem focused and not EPF.  According to the E/M Documentation Guidelines a Problem Focused exam is "a limited examination of the affected body area *or* organ system.  An Expanded Problem Focused exam is "A limited examination of the affected body area *or* organ system and other symptomatic or related organ systems.
> 
> If you look at this exam as body area then you have one plus the VS which still meets the requirements for EPF.



*Big lightbulb moment here* - In looking at my E&M worksheet, I believe there is an error. Our facility has put together this worksheet based on several that are available on the web, and it states:

PF exam is "1 affected BA/OS."  
*EPF is "1 affected BA/OS *AND* 2-7 OS, limited."  *
Detailed is "affected BA and 2-7 OS, one detailed."  
Extended is "8+ OS or 1 complete OS exam."

Correct me if I'm wrong, but isn't the bolded line incorrect? Shouldn't that say "2-7 BA/OS"?

Thank you so much for your help, everyone! This has helped immensely...so much so that I'm going to post another question I have on ROS.


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## dclark7 (May 12, 2015)

The bolded line is incorrect, the next line is incorrect also.  The CMS E/M services guide describes a detailed exam as "an extended examination of the affected body area(s) and other symptomatic or related organ systems."  The 2-7 or whatever number required is usually dependent on your MAC, but is not actually spelled out by CMS.  You can get a copy of the actual guidelines on the CMS website to show whoever is in charge of your worksheet and hopefully get this corrected.  http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf


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## LLovett (May 13, 2015)

The pain and minimum standards comments are based on some of Debra's responses copy/pasted below, I added the bold.

" Also to exam the puncture site and look for redness and drainage is the *minimum that must be performed*, what else about the exam of the affected areas makes this a detailed exam? I see nothing in what you have stTed that is beyond the basics. There is no mention of a foreign body still present, *the degree of pain*, or anything thing else, so if you are trying to "push" this to a level 4 visit, then my advice is to go with a level3 as that I can see as supported by the medical necessity and the document."


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