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elenax

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Dear Auditors/Experts/Gurus:

I need clarification on how to determine the exam type for the scenario below based on the 1995 guidelines. I would appreciate your help and rationale on which BA or OS including the exam details I need to take in consideration to determine the exam type for the patient's CC of back.

Here is the scenario:

HPI:

Patient states pain located in central back. It is sharp and radiating and the pain scale is 3/10.

EXAM:

Head : normocephalic, atraumatic.
Eyes : Normal conjuntivae, anicteric sclera. Both lids are normal.
Neck : Neck is symmetric, trachea is midline.
Chest : Repiration appeals normal. non-labored.
Cardiovascular : Heart has regular rates and rhythm
Musculoskeletal : Gait is normal. Lumbar spine reveals well healed scar. ROM
of lumbar spine is normal but with pain. Lumbar spine is
stable. The straight leg raising test is negative. There is a
BI facet tenderness to palpitation. Left lower extremity is
normal in inspection. Palpitation is normal. ROM is normal.
The left lower extremity is no join instability.
Right lower extremity is normal in inspection. Palpitation is
normal. ROM is normal. The Right lower extremity is no
joint instability.
Psychiatric : Proper orientation to time, place, person. Patient's mood is
euthymic. An appropriate affect is observed.


Assessment : DX. 722.83 post-laminectomy syndrome of lumbar region
724.2 Lumbago
Stability: Stable

Your help would be greatly appreciated!!!
 
Are you trying to figure out the Chief Complaint? Central back is included in thoracic . Lumbar is lower back. L1-L5. I'm not exactly sure what your asking. All I see is the HPI, and Physical Exam. Where is the Review of symptoms that would coincide with the CC? I'm just trying to help. The diagnosis is your standard low back pain.

Marcie -CMA coding student
 
This would qualify as a detailed exam (defined under 1995 guidelines as "an extended examination of the affected body area(s) and other symptomatic or related organ system(s).") You have 5 body areas (Head, Neck, Chest, 2 lower extremities) or 5 organ systems (Eyes, Respiratory, Cardiovascular, Musculoskeletal and Psychiatric) with extended information about the affected area as well as information about the related systems.
 
The reason I questioned this scenario is because we were told that the affected body area would be the back and the related organ system would be the lower extremity, If I choose the body areas I can only consider the back and lower extremity and if I choose the organ systems I can only consider the musculoskeletal section because there is no 'other organ system related to the back' which would qualify the exam only for a PF or EPF depending on BA's or OS's chose. The way I used to determine the exam agrees with Thomas7331's rationale.

I just would like to have more feedback on what is considered or how do you determine what organ system is related to the back in this case.

Thank you all for your replies;)
 
I'd be interested to hear others' thoughts on this. Actually, I think that this would be a really good question to discuss with the provider.

My take on it is that, just like determining medical necessity, coders aren't the best qualified to know what systems need to be checked or are potentially involved when a patient presents with a particular symptom. I generally operate under the assumption that if a provider performs an exam of an area or system, then there's a reason for it and every time I've discussed it with a provider, they're able to explain why they did it. As a coder, I wouldn't want to be in the position of making the call to 'disqualify' a provider's exam work as unrelated to a problem. And I've never run into an audit situation where this has been approach a problem.
 
I think it's safe to say that if a patient presents with back issues that we're definitely going to be wanting to see exam components from the MS system at the very least, with neuro, CV and resp commonly accompanying that. However, most providers, regardless of their specialty have their 'standard' exam that they like to use as a matter of course. Coders have an opportunity to educate the providers about the medical necessity of an examination of OS/BA that appear irrelevant to the CC without at least some indication in the A/P as to whether or not there was something going on in the provider's head when he chose to examine. Was there a previous issue he was following up on? Is there a symptom in another BA/OS he wanted to check to rule out a condition related to the CC? Knowing why they examined areas other than the one relative to the CC not only supports medical necessity, but increases the LOS that can also be supported. I wouldn't discount a seemingly non-related exam component, however.

Coders should also make it their business to learn what the examination components are evaluating; you're a better coder when you know what your provider is up to, and you can be sure that medical review staff in the payer office are clinicians, so they know what the provider is up to as well. For example, in this detailed examination example, although you might want to include the "straight leg raising test" as part of the MS exam, the provider is indeed checking for sciatic nerve issues, which both would be related to the CC.

Good discussion.
 
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