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Hospitalist physical exam for E&M
By Richard Pinson, MD, FACP
Together with history taking and medical decision making, physical examination is one of the three key components for assigning evaluation and management (E/M) levels of service. Physicians are frequently instructed to follow either 1995 or 1997 guidelines from the Centers for Medicare and Medicaid Services (CMS), which support four types of physical examination: problem focused, expanded problem focused, detailed and comprehensive.
But, from a clinical standpoint, perhaps it's not necessary for hospitalists to worry so much about all these technical rules and criteria. After all, aren't we physicians the real experts who know what a physical exam should be? All of us were taught the art and science of physical diagnosis in medical school, and those skills have been sharply honed ever since. The following is an intuitive, clinical approach to simplify the hospitalist's task of providing optimal documentation of physical examination.
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Unlike outpatients, hospitalized patients (whether receiving inpatient or observation care) typically have significant or even potentially life-threatening illness. This usually necessitates a comprehensive initial examination and very thorough subsequent evaluations.
Physicians are most familiar with a physical exam that follows a simple systematic assessment of the body, usually performed from head to toe. The 1995 CMS guidelines for physical examination use this approach. The exam can be based on specifically defined “body areas” or “organ systems.” The organ system model is probably the most convenient and efficient. Physicians who use these organ system terms to identify the sequential areas examined will clearly document the correct E/M level of service and avoid ambiguity if a chart audit occurs.
The organ systems for physical examination are: constitutional (general appearance/vital signs); eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; and lymphatic. Hematologic and immunologic are included in “lymphatic,” but how these two terms relate to physical examination is a little unclear.
The 1997 CMS guidelines are unnecessarily complicated for hospitalists and require calculation of “points” for “bulleted items” (see Sources list on next page for more information). They are most appropriate for specialists who perform single organ system examinations.
The types of E/M examinations are listed in the table below, but how does one interpret this information?
For almost every initial encounter, such as the admission history and physical (H&P), hospitalists normally perform a comprehensive exam that includes at least eight organ systems, and often more. For seriously or critically ill patients, many subsequent visits also will require examination of eight or more organ systems.
The difference between detailed and expanded problem-focused exams may seem ambiguous since both call for examination of two to seven organ systems. Because a detailed exam ought to include more organ systems than the expanded problem-focused exam, many experts suggest that five to seven systems would be most appropriate for the detailed exam. Some CMS contractors also specify five to seven organ systems for a detailed examination.
In clinical practice, examination of at least five organ systems is probably needed for most subsequent hospital visits. However, many hospitalists may evaluate more organ systems than they realize and fail to document all those they examined. For example, wouldn't the patient's constitutional appearance and vital signs always be pertinent? Isn't it almost always appropriate to examine the eyes and mouth for state of hydration, jaundice or thrush? The skin would typically be checked daily for evidence of any new rash, petechiae or possibly cellulitis (especially with an IV catheter). What about auscultation of the lungs or palpation of the abdomen for tenderness or a liver edge? Is there new edema or calf tenderness, perhaps evidence of the deep venous thrombosis so common among hospitalized patients? Do the patient's mental status and speech matter today? Always include information like this in the physical exam section of your daily progress note.
Why does the number of organ systems examined (and therefore the type of examination performed) on each visit matter so much? Because the highest level of initial inpatient and observation E/M services requires a comprehensive exam (eight or more organ systems), and the highest level of subsequent inpatient and observation E/M services requires a detailed examination. The final level of service billed for each encounter will also depend on the extent of the history (or subjective component) and/or the complexity of medical decision making, but don't shortchange yourself on the physical exam.
Of course, the exam must be pertinent to the patient's condition on that date of service, but as discussed above a comprehensive exam is almost always pertinent for the initial hospital encounter, and a detailed exam clinically appropriate for most subsequent visits.
In summary, use your hard-earned clinical skills to conduct an appropriate physical exam every day. Use the organ system terms to identify the sequential areas of your physical exam. Document everything you see, hear and feel. Include pertinent areas like general appearance and vital signs (constitutional), skin, eyes, mouth, lungs (respiratory), extremities (musculoskeletal), and mental status (neurologic). If you follow this good clinical practice, the technical E/M rules and criteria for physical examination will take care of themselves.
Richard Pinson, MD, FACP, is a certified coding specialist and cofounder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.
- Current Procedural Terminology, Fourth Edition. American Medical Association. 2012.
- Evaluation and Management Services Guide. Medicare Learning Network (MLN). December 2010.
- Medicare E&M Service Coding and Audit Worksheet. E-Med Tools.
- E&M CPT® Coding Review and Audit Tool. MDTools.
Ask Dr. Pinson
Q: I work with a group of hospitalists who are billing their professional fees using the hospital's principal discharge diagnosis. I believe this is not correct, and that they should be reporting the ICD-9 code for the conditions treated on the date of service. Currently, they wait until the hospital record is coded and use the principal diagnosis reported in the IP record.
A: The practice you describe is not correct. The hospitalist's initial and subsequent encounters should indicate all the conditions and diagnoses that are being managed on a particular day of service. Diagnoses listed on the claim for each day of service should match the conditions that were documented.
Many of these diagnoses will change from day to day as the patient's stay progresses and more specific diagnoses emerge or are clarified. For example, it may not become apparent for a few days that abdominal pain on admission was actually caused by cholelithiasis. The hospitalist's notes and claim should say “abdominal pain” for the days prior to confirmation of cholelithiasis, and then the more specific diagnosis for the remaining days of treatment.
All conditions being managed on each day of service should be documented using precise clinical terminology even if they seem minor or interrelated. Assignment of the correct E/M level of service often depends on the number of diagnoses under management on that day and the associated risks to the patient. If more conditions (up to four) are documented, assignment of a higher level of service is likely, especially when the conditions represent greater risk to the patient.
Finally, as the patient's condition changes throughout the admission, the status of each diagnosis should be described in the daily progress notes as applicable: worsening, unchanged, improving, resolved, or new problem. Not only does this allow the progression of care to be readily identified, but correct assignment of the E/M level of service is enhanced. Using a non-specific term like “stable” or “uneventful” may create ambiguity about the level of service and may suggest that inpatient care is no longer needed.
Got a documentation or coding question? Dr. Pinson will respond immediately, and the question may then appear in an upcoming issue of ACP Hospitalist. Please e-mail your questions directly to us.
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