TABLE 3
The respiratory exam: What’s included*
| SYSTEM/BODY AREA | ELEMENTS |
|---|---|
| Constitutional | • Measurement of any 3 of the following 7 vital signs: 1) sitting or standing BP 2) supine BP 3) pulse rate and regularity 4) respiration 5) temperature 6) height 7) weight • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) |
| Head and face | |
| Eyes | |
| Ears, nose, mouth, and throat | • Inspection of nasal mucosa, septum, and turbinates • Inspection of teeth and gums • Inspection of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, and posterior pharynx) |
| Neck | • Examination of neck • Examination of thyroid • Examination of jugular veins |
| Respiratory | • Inspection of chest with notation of symmetry and expansion • Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) • Percussion of chest (eg, dullness, flatness, hyperresonance) • Palpation of chest (eg, tactile fremitus) • Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) |
| Cardiovascular | • Auscultation of heart, including sounds, abnormal sounds, and murmurs • Examination of peripheral vascular system by observation and palpation |
| Chest (breasts) | |
| Gastrointestinal (abdomen) | • Examination of abdomen with notation of presence of masses or tenderness • Examination of liver and spleen |
| Genitourinary (abdomen) | |
| Lymphatic | • Palpation of lymph nodes in neck, axillae, groin, and/or other location |
| Musculoskeletal | • Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements • Examination of gait and station |
| Extremities | • Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes) |
| Skin | • Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) |
| Neurological/psychiatric | Brief assessment of mental status, including • Orientation to time, place, and person • Mood and affect |
| BP, blood pressure. | |
| * What you are required to do: | |
| Level of exam: Perform and document Problem focused: 1-5 elements identified by a bullet Expanded problem focused: ≥6 elements Detailed: ≥12 elements Comprehensive: Perform all elements, document every element in each shaded box and ≥1 element in each unshaded box. | |
| Source: American Medical Association; 2008.1 | |
QUESTION 6: Should inpatient codes be used for preop consults in a hospital?
Answer: C It depends. While you’ll typically use inpatient codes, there are exceptions. Patients who are in the hospital but assigned to observation status, in the outpatient surgery area, or in the emergency department and not subsequently admitted, are considered outpatients. Thus, encounters with patients under such circumstances should be billed using outpatient codes.
What’s your score?
Give yourself 1 point for each question you answered correctly. If you scored 5 or better, you’re a coding genius. Please come to my office and help me run my practice!
If you scored 4 or lower, take the opportunity to learn more about coding. Go to http://www.cms.hhs.gov/MLNEdWebGuide, a Centers for Medicare and Medicaid Services site featuring downloadable publications, interactive tutorials, and other coding tools (click on “Documentation Guidelines for E&M Services”). The American Medical Association Web site is also a valuable source of E/M coding. At www.ama-assn.org/ama/pub/category/3113.html, you’ll find CPT/RVU Search, a free search engine you can use to learn more about the relative value unit system and review reimbursement rates for your geographic region.
Correspondence
Edward Onusko, MD, Clinton Memorial Hospital/University of Cincinnati Family Medicine Residency, 825 West Locust, Wilmington, OH 45123; edonusko@cmhregional.com