EM Coding Alert

Question: I have heard of the 4 x 4 rule, but I don’t understand what that really means. Can you explain?

California Subscriber

Answer: The 4 x 4 rule is a way some payers differentiate between an expanded problem-focused exam and a detailed exam. The 4 x 4 way of counting means your physician examines at least four elements in any four body areas orany four organ systems to reach a detailed exam.

Scenario:  A 30-year-old patient comes in to see the physician for symptoms that could relate to a cold, pneumonia, flu, or mononucleosis. The physician performs a detailed examination per the 4 x 4 rule as follows:

• Constitutional: Temperature of 99.1 degrees, respiration is normal, blood pressure is 121/65, weight is 169, and height is 66 inches. Patient appears to be her stated age and mildly distressed
• Ears, nose, and throat (ENT): Nares moist, and nose red, throat is pink, ears within normal limits (WNL), and a slightly swollen gland on the right side
• Eyes: Pupils of the eyes are equal, round, reactive to light, reactive to accommodation to light (PERRLA)
• Cardiology: Regular rate or regular rhythm, no edema, no carotid bruits, bilaterally
• Respiratory: Auscultation bilaterally, oropharynx midline, and non-labored breathing
• Gastrointestinal (GI): Abdomen is soft, non-tender, no hernias, and no organomegaly.

Findings: The physician’s exam resulted in six elements for constitutional, five for ENT, four for eyes, five for cardiology, four for respiratory, and four for gastrointestinal. You can count the elements found in the patient’s record for at least four body areas or organ systems, thus making this a detailed exam.

Be aware: Some payers, such as Novitas, count PERRLA as four exams as noted above. Other payers only count PERRLA as one exam. You should always keep your  finger on the pulse of your local carrier.