Wiki what is the level of exam? HELP!!

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CodingMari

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could someone shed some light I am a new coder. I think I need a profound course in E/M

example:

VS: 135PD Height: 61in Temperature 98.90 respiratory rate: 96% o2 saturation: 2532 blood pressure: 138/84

chronic diags:
anxiety disorder
COPD
chronic neck pain
Dvt of leg


Subjective
patient needs meds refills

ROS looks to me like it was copy pasted

objective:
GENERAL: alert patient in no acute distress
SKIN: normal no abnormal erythema or lesion noted
HEAD: normocephalic, no signs of trauma
EYES: peerl pupil mid sized, eoms are intact, fundi are benign
EARS: canal are clear, tympanic, membranes are normal
NOSE: septum is intact and midline
THROAT: pharynx is clear. no masses noted
NECK: supple, thyroid not palpable, carotids 2+ bilatelally and equal no bruits were noted
HEART: RRR S1 S2 are present no heaves rubs or murmurs are heard pmi is the 5th intercostal space, mid clavicular line
CHEST: clear to percussion and some rhoinci on auscultation bilaterally
abdomen: soft non tender without guarding masses rebound or organomegaly bowel sounds are normal.EX
EXT: are intact and show no signs of trauma pulses: brachial, radial, femoral, dorsalis, pedis and posterior tibial are 2+bilaterally and equal. no clubbing is noted. capillary refills is within normal limits
mental status patient is alert and oriented x3 effect is WNL.

assessment
anxiety stable, copd, nicotine dependence

plan:
refill medication
review life style changes
recheck apt

I am wondering how many bullets I have for the exam? and how many in the HPI?
 
I audit E/M records and this claim would be denied. The CC is not documented. Refill on a RX is not necessarily warranting an actual E/M service. A full ROS is not pertinent to the patient's presenting problems.
 
I get somewhat confuse with the whole ROS and Exam

I am seeing a chief complaint of f/u on prescriptions refill with no was no chief complaint because the patient was not experiencing and problems.

The prescription is Alprazolam (xanax)

then provider documents constitution, eyes, ears, cardiovascular, gastrointestinal, musculoskeletal, neurological, endocrine which were all negative. then is goes to objective which was noted above. ROS is 7?

So I have 10 bullets for exam which is EPF
and the MDM bullets to cover these was one stable chronic illness (anxiety)? no data pts and problems pts 1(establish problem stable and improving)?

I really appreciate the feed back.

what course would any of you recommend so I can polish up on my coding?
 
Whenever there is an E/M visit, there MUST be a chief complaint documented. So from what I see, the patient presented with no complaints therefore that would not warrant a Medically Necessary E/M visit.

The other question would by, why a ROS of 7 systems, and why a full exam if there are no problems? One thing to remember, is you are not just counting systems, you are looking at the documentation as a whole.


Here is the link to CMS E/M documentation guidelines. I have audited for many years, and I still reference to these guidelines periodically.

https://www.cms.gov/Outreach-and-Ed...oducts/MLN-Publications-Items/CMS1243514.html

Hope this helps!
 
Missy, thank you for replying to this post, I do appreciate the feed back. I have that reference on hand but was confuse with the providers documentations. It threw me off!! I was thinking I was not understanding the guidelines. its clear the providers need education.
 
You're welcome. I also educate physicians and NPP in addition to billing staff. I find that creating a cheat sheet for the physicians to reference to, makes it easier because I do not know very many physicians who have the time to read 89 pages of the guidelines. I have also created "Dummy Records" that are driven directly to that provider's scope of practice so they can get an actual visual of what Auditors are looking for. That may be something you will find is productive when you educate your providers.
Plus, the guidelines are not always clear and concise. There are some grey areas that are left open to interpretation.
Good luck and take care!
 
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