# Podiatry E/M?



## MarciaH (Mar 13, 2009)

Being in a Podiatrist office we don't have the review of systems that you would have in a family practice office or other specialties but you still need ROS to code office calls. I'm super frustrated over this. How am I to know how to code an office call when we don't have the usual ROS? Someone PLEASE help guide me in the right direction!!
Thanks!


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## rthames052006 (Mar 13, 2009)

MarciaH said:


> Being in a Podiatrist office we don't have the review of systems that you would have in a family practice office or other specialties but you still need ROS to code office calls. I'm super frustrated over this. I graduated in June, am a CPC-A, and have an office manager who has NO coding/billing education. She only knows what has gotten paid in the past. How am I to know how to code an office call when we don't have the usual ROS? Someone PLEASE help guide me in the right direction!!
> Thanks!



Are you saying that their is NO ROS at all in the notes you are reviewing.?  As for your office manager you should show her some "official" documentation regarding coding rules/guidelines or even an audit worksheet to educate her in some way-shape or form; hopeuflly she is receptive if you approach her in this way.

I wish you luck.


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## FTessaBartels (Mar 14, 2009)

*Patient History Questionaire*

I work in pediatrics ... how do you review sytems for a 1 month old?  Yet, it's still a requirement.

It would be a good idea to have a patient history questionaire that is completed by the patient at least annually. You might not feel you need all 14 systems, but I can imagine it would important to know if the patient had ever had:
fractures
arthritis
diabetes
tingling in extremities
clubbing
cyanosis
weakness
nail fungus
lesions

You get the idea. 

The patient completes the form. The podiatrist reviews and signs/dates the form. Voila ... you have your ROS (also past medical, family and social history).

Hope that helps

F Tessa Bartels, CPC, CEMC


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## rthames052006 (Mar 14, 2009)

FTessaBartels said:


> I work in pediatrics ... how do you review sytems for a 1 month old?  Yet, it's still a requirement.
> 
> It would be a good idea to have a patient history questionaire that is completed by the patient at least annually. You might not feel you need all 14 systems, but I can imagine it would important to know if the patient had ever had:
> fractures
> ...





That sounds perfect to me ( although I'm not in Podiatry)... you really have some great ideas Tessa.... glad your a part of this forum, I get great ideas/tips from your posts on a regular basis.

Thanks!


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## feliciathomas (Mar 15, 2009)

I agree with her... You really give good information in your posts... I find myself looking for your name and reading your suggestions.  

Thanks for being a good resource for those of us with little or no experience.


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## FTessaBartels (Mar 16, 2009)

*Thank you (blushing)*

Felicia & Roxanne, 
Thank you for your kind words. I'm glad I can be of some help.
I read all the posts, and try to answer those I feel competent to respond. 

Sometimes just asking an additional question is all someone needs to point them in the right direction. 

F Tessa Bartels, CPC, CEMC


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## MarciaH (Mar 25, 2009)

Thanks for all the responses. 

I have an example of what I was talking about. This is actual dictation from one of the doctors. 
"S: This patient is seen in the office today with history of diabetes. He is 67 years old with good to fair glucose levels. He is using diabetic shoe gear. He is here for preventive care.
O: Soles of feet show mild scaling and erythematous eruptions consistent with active tinea. No cellulitis. Heals are showing mild dryness and keratinization. No fissuring or ulcers otherwise. DP and PT pulses are palpable with tactile sensation intact. Nails are thickened, dystrophic and elongated x 10 requiring reduction.
A: 1) tinea pedis. 2) heel tylomas. 3) diabetes. 4) Onychodystrophy. 
P: reduced nails and thickness. Keratinized areas of the heels were reduced without incident. Rx for Lotrisone. Continue use of appropriate shoe gear. Appointments every 10 weeks."
I was told to code this as:
99213
7011 - callous
1104 - tinea pedis
7354 - hammer toe

I don't agree with the E/M code or the hammertoe code as hammertoe was not discussed in dictation. I don't feel there is enough to warrant a 99213.

These are the things I deal with on a daily basis, only sometimes worse. If I approach my office manager about it, she says "Just code it, it will get paid!" I would quit if I wasn't in a position where I have to have a job (hubby is out of work). I'm currently looking for another job but this one has me frustrated to the point that I know it is wrong but no one cares so why should I. I don't want to jeopardize my degree and credentials so this is a BIG internal struggle on a daily basis!

I should also state that yes, I am the coder/biller but I am also to be helping the receptionist answer calls, check patients in and out, along with any other duties the office manager sees fit to drop on my desk. With that being said, I don't have the time that I should to review each chart. I'm told to bill from what the doctor has marked on the encounter form.

Thanks for listening to my rant!


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## FTessaBartels (Mar 26, 2009)

*1995 guidelines*

Marcia,
I hear your frustration.

First let me address you problem w/ ROS ... Just because there isn't a separate paragraph heading marked ROS doesn't mean that you *never* have an ROS. Let's look at *THIS* note.
Chief complaint: preventive visit, Hx of DM
HPI - Severity:  "*fair* glucose level"
ROS - musculoskeletal - wear diabetic shoes

I'll admit I'm stretching it here by counting the diabetic shoes as MS for ROS, but you get the idea. This is enough for an EPF history.

NOW ... even more important to your understanding, you do *not *even need the history on this note to get to a 99213.

Using the 1995 guidelines your exam has 3 systems:
Cardiovascular - pedal pulses
Skin - rashes/lesions
Musculoskeletal - exam of nails

This equals an EPF exam under the 1995 guidelines.

Now let's tackle the MDM:
Problem points:  I get a total of 4
1 pt for DM established, stable
3 pt for tinea pedis (new problem, no workup)

Data points:  none

Risk:  Moderate  due to Rx for Lotrisone

For an established patient you only need to meet 2 of the 3 key elements of the E/M.  With an EPF exam and moderate MDM you easily get 99213.

I agree with NOT coding hammertoe. It's not even mentioned anywhere. But you should definitely be coding the diabetes.  

Also, since I don't code for podiatry *I'm not sure about this *... but is the nail trimming separately reportable for a DM patient? (I'm thinking maybe 11721?)

Finally, Marcia ... you are right that the podiatrist needs to improve his/her documentation. A few simple phrases would go a long way to allowing the doctor to capture the charges for the kind of service s/he is actually providing.  At least once a year you should have your patients complete a patient history questionaire ... this could include the ROS and past medical/family/social history. The doctor would review, sign and date this form, and then could reference it in the dictation. 

For DM patients, I think you might want to have some notation of when the patient last saw his/her PMD (or endocrinologist). Some statement as to whether this is Type 1 or Type 2, controlled or not controlled. 

I hope this helps. I've also sent you a private message.

F Tessa Bartels, CPC, CEMC


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## MarciaH (Mar 26, 2009)

F Tessa,
Thanks so much for helping me see that there really is more there than what I seen! I really need to find a "checklist" for ROS, HPI and MDM to take to work. I believe that would help me greatly! (I'm locating one as soon as I'm done with this post.) We do have the patient fill out a history sheet once a year but the doctor's don't reference it in their dictation.

I realize I forgot to say in my second post that we do ask the patients when they last saw their PCP and note that in the chart. As far as the nail trimming, if the patient has DM, we usually do code the 11721 with modifier -25 on the office call, just not in the case I used as an example. I'm not exactly sure of the reason of why they do it on some and not others. I'll ask on Monday when the office manager is back.

Once again, Thank You for all your help!


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## FTessaBartels (Mar 27, 2009)

*Smoking*

Our local chapter had a podiatrist as our speaker this month. One item she mentioned is that she ALWAYS makes note of whether the patient (and/or family members in the same household) is a smoker.

This serves two purposes. 

It's *medically important *especially for DM patients because their circulation is compromised by the DM and further compromised by the smoking. 

But by always noting it in her documentation the podiatrist is covering *social history*.  That one little phrase about smoking allows her to get a detailed history. (Assuming HPI and ROS are there, too.)

F Tessa Bartels, CPC, CEMC


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