# Am I being too picky?



## btadlock1 (Mar 10, 2011)

I'm trying to grade an outpatient E/M (family practice office visit), and I'm not comfortable giving credit for some of the statements in the exam (we use 1997 guidelines only)...I don't know if I'm over-analyzing this, but it seems like these statements are too vague to really qualify for a bullet...Please let me know what you think...

Cardiovascular - Normal rate, regular rhythm
HENT: Normocephalic
Lymphatics: No lymphadenopathy
Musc.: Normal range of motion; normal strength. 

Do any of these count?
Thanks!


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## btadlock1 (Mar 11, 2011)

*I still need help!!!*

Anybody???


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## MMAYCOCK (Mar 12, 2011)

Here is a link to a previous post. 
https://www.aapc.com/memberarea/forums/showthread.php?t=26528


You do not have to find a problem to count a bullet. Maybe a good question to ask yourself is what you think the phrasing should be? How would he/she state that the patient's CV system was examined and has no issues? Same for lymphatic system and the muscular? if he checked the range of motion and the muscle strength, what would be missing other than that he/she seems to use an economy of words to describe the exam?


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## btadlock1 (Mar 12, 2011)

MMAYCOCK said:


> Here is a link to a previous post.
> https://www.aapc.com/memberarea/forums/showthread.php?t=26528
> 
> 
> You do not have to find a problem to count a bullet. Maybe a good question to ask yourself is what you think the phrasing should be? How would he/she state that the patient's CV system was examined and has no issues? Same for lymphatic system and the muscular? if he checked the range of motion and the muscle strength, what would be missing other than that he/she seems to use an economy of words to describe the exam?



It's not necessarily that nothing was wrong, it's that the places being examined don't seem to meet the criteria of the bullets. For example:
*Cardiovascular - Normal rate, regular rhythm *- is not really a bullet at all, as far as I can tell. It's sort of covered under the vitals in Constitutional, but that's all the doctor says - should there be credit under CV? And where?
"_*Constitutional*: Measurement of any three of the following seven vital signs: 1) sitting or
standing blood pressure, 2) supine blood pressure, 3) *pulse rate and
regularity*, 4) respiration, 5) temperature, 6) height, 7) weight (May be
measured and recorded by ancillary staff)...
*Cardiovascular*: Palpation of heart (eg, location, size, thrills)
-Auscultation of heart with notation of abnormal sounds and murmurs
-Examination of:
-carotid arteries (eg, pulse amplitude, bruits)
-abdominal aorta (eg, size, bruits)
-femoral arteries (eg, pulse amplitude, bruits)
-pedal pulses (eg, pulse amplitude)
-extremities for edema and/or varicosities_"

*HENT: Normocephalic* - On this one, I get that the head appears to be a normal shape - but once again, that doesn't really fit under any particular bullet - is he referrling to the external ears? Lips? Nose? Do I give credit under more than one bullet, or none at all???
DG:"*Ears, Nose,
Mouth and
Throat*:
_-External inspection of ears and nose (eg, overall appearance, scars, lesions,
masses)
-Otoscopic examination of external auditory canals and tympanic membranes
-Assessment of hearing (eg, whispered voice, finger rub, tuning fork)
-Inspection of nasal mucosa, septum and turbinates
-Inspection of lips, teeth and gums
-Examination of oropharynx: oral mucosa, salivary_"

*Lymphatics: No lymphadenopathy* - This one specifies that the provider must examine lymph nodes in two or more areas, so wouldn't those need to be documented in detail? Or should I assume he checked all of them? I'm not comfortable with that....
DG: "_*Lymphatic*: Palpation of lymph nodes in two or more areas:
Neck
Axillae
Groin
Other_"

*Musc.: Normal range of motion; normal strength.* - My problem with this one is the same as lymphatic - the guidelines are specific enough to state that certain areas have to be documented as examined, and this is a vague statement. What has normal ROM? Their back? Or Neck? Or just their arms and legs?

"_Examination of joints, bones and muscles of *one or more of the following six areas*: 1)
head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity;
5) right lower extremity; and 6) left lower extremity. The examination of a given area
includes_:..."

My biggest concern with this documentation is that it appears to be auto-populated by an EHR template, and not genuinely entered after an actual observation. But I don't want to read too much into the guidelines, either; I just want to make sure I'm being fair, while not allowing anyone to have a false sense of security about what's good enough to 'count' in their records. I'm not trying to be argumentative- I genuinely need help!!! Any thoughts?


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## mitchellde (Mar 12, 2011)

Brandi,
I am agreeing with you and I know from experience that my opinion on this is not popular.  However I did an audit for a service and pretty much said what you are saying that it just was not specific enough for the 97 guidelines, especially the musclulosckeletal one since it really must be specific to extremity in order to count.  So they had another person do the same review, she was more lenient and read more into the assements that I had done so of course they liked her assesments better.  The result was they got the answer they wanted and continued on their merry way.  But as all good stories this one has not the happy ending as they were ultimately audited by 2 different carriers for essentally the same reason and they did not find the visit levels such a good match to the billed levels and requested several dollars be refunded.  
While I agree they do not need to write a novel, nor do they have to have a problem finding, I do not think they can be so generic in their patient assessment.  My opinion!


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## btadlock1 (Mar 12, 2011)

mitchellde said:


> Brandi,
> I am agreeing with you and I know from experience that my opinion on this is not popular.  However I did an audit for a service and pretty much said what you are saying that it just was not specific enough for the 97 guidelines, especially the musclulosckeletal one since it really must be specific to extremity in order to count.  So they had another person do the same review, she was more lenient and read more into the assements that I had done so of course they liked her assesments better.  The result was they got the answer they wanted and continued on their merry way.  But as all good stories this one has not the happy ending as they were ultimately audited by 2 different carriers for essentally the same reason and they did not find the visit levels such a good match to the billed levels and requested several dollars be refunded.
> While I agree they do not need to write a novel, nor do they have to have a problem finding, I do not think they can be so generic in their patient assessment.  My opinion!



Much appreciated! Thank you!


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## btadlock1 (Mar 14, 2011)

*While we're on the subject...*

I have another one...
Under Psychiatric, the doctor has a note that says:
"Cooperative, Appropriate Mood and Affect", and he also has a note that says "Cognition and Speech: Oriented, Speech Clear and Coherent."

So, using 1997 guidelines, I've given a bullet under psych for:
-orientation to time, place and person
-mood and affect

My question is, would the "speech clear and coherent" or "cooperative" statements count as a description of the patient's judgement and insight? And if not, could I please get an example of what would count? Thanks!


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## FTessaBartels (Mar 15, 2011)

*Conservative approach*

I tend to follow the more conservative approach that Debra outlined.  You either document exactly what the bullet is asking for or you get no credit.  * OR* - you use 1995 guidelines which are much more flexible. 

But you've already stated this practice is using 1997 exclusively.  Well, they think they are. 
Looks like you have some physicians who learned to document under 1995 and think they can use the same verbiage and still get the bullets under 1997.

As to the specifics of your second scenario ... (I think Debra covered the first one)
The bullet for psych is "oriented to time, place and person" ... so the documentation has to either state that in full *-or-* state "oriented x 3"   -* no *credit for "oriented" all by itself.  DOES get a bullet for "appropriate mood and affect"


NOW ... if you are using the 1997 PSYCHIATRIC exam template (vs the general multi-system exam) ... here are the bullets (ALL of which are needed for comprehensive exam)
* Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities
* Description of thought processes, including: rate of thoughts; content of thoughts; abstract reasoning; and computation
* Description of associations
* Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions
* Description of the patient's judment and insight
Comp[lete Mental Status Exam including:
* Orientation to time, place and person
* Recent and remote memory
* Attention span and concentration
* Language
* Fund of knowledge
* Mood and affect


Hope that helps.

F Tessa Bartels, CPC, CEMC


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## btadlock1 (Mar 16, 2011)

FTessaBartels said:


> I tend to follow the more conservative approach that Debra outlined.  You either document exactly what the bullet is asking for or you get no credit.  * OR* - you use 1995 guidelines which are much more flexible.
> 
> But you've already stated this practice is using 1997 exclusively.  Well, they think they are.
> Looks like you have some physicians who learned to document under 1995 and think they can use the same verbiage and still get the bullets under 1997.
> ...



It does - thank you! What about 'cooperative'? Would that count as a description of the patient's judgement and insight?


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## FTessaBartels (Mar 16, 2011)

*Cooperative*

Nope .... 

F Tessa Bartels, CPC, CEMC


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