# General Surgery template for E/M



## DebbiePottsEngland (Jun 3, 2010)

Does anyone have a template for General Surgery Evaluation and Management?  How do they have a medically necessary 97 guideline visit?


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## FTessaBartels (Jun 24, 2010)

*Template*

You are concerned about medical necessity. If you are planning to take someone to the OR there is a lot besides just the presenting problem that you need to take into account. 

I don't have a template but here are things to have your surgeons consider.

For 99204 and 99205 you MUST have a comprehensive exam ... no way around it, you need 2 bullets for each of 9 systems.

For 99203 you need a detailed exam ... 12 bullets from 2 or more systems

Here are bullets that I would consider medically necessary for most general surgeons
CONSTITUTIONAL - general appearance, 3 vital signs
ENT - exam of oropharynx, inspection of lips, teeth, gums (if patient will be intubated for anesthesia it's medically necessary to examine these)
RESPIRATORY - assessment of resp effort, auscultation of lungs
CARDIOVASCULAR - auscultation of heart, examine extremities for edema
LYMPHATIC - palpate lymph nodes in two areas (checking for infection)
GI - Examine abdomen w/ notation of masses or tenderness,  note presence/absence of hernia, or any other bullets necessary based on type of surgery required
PSYCH - description of patient's judgment or insight, orientation x 3 (you want the patient to be capable of making an informed decision)
*(note - at this point you easily have a detailed exam)*
MUSCULOSKELETAL - Examine digits & nails for clubbing or cyanosis (good for everyone) - other bullets as appropriate for patient condition and surgery contemplated
GU - as appropriate for gender and type of surgery
CHEST - as appropriate for type of surgery
SKIN - as appropriate for type of surgery
NEURO - as appropriate for type of surgery


If all your surgeons want to do is examine the actual hernia (as an example), then they will be limiting the coding to 99201.  It's their choice.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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