ED Coding and Reimbursement Alert

Question: Does a drawing (artistic rendering) of a body part in the exam component of the medical record count as an element toward the E/M level? 

Missouri Subscriber

 
Answer: There are no limits on the use of graphic information to meet documentation requirements. If the information is contained in a physician-drawn image, treat that information as though it were text. As long as the data are not ambiguous, they can be used.
 
For example, if an ED physician has a drawing of a torso and shades in an area that he or she labels as tender, it is pretty clear what the physician is documenting. However, if the diagram has no descriptors, it becomes difficult to determine the problem. Most trauma centers use a human picture isolating the face and abdomen with specific symbols to illustrate findings such as tenderness, abrasions and lacerations.
 
As always, it is best to use common sense. Ask yourself, Does this make sense to me? or Would it make sense to someone else (an internist, a surgeon, an auditor, a lawyer)? If the answer is yes, use the drawing in the documentation.
 
As always, it is best to ask the carrier in question for a copy of its policy.