Ethical Question re: Documentation of PE

[AlienHand]

During my ED rotation, I noticed that most, if not all, of the residents dictated a physical exam that was far more complete than the exam that was actually performed. I assumed they were just being lazy, or perhaps trying to cover themselves from a medicolegal standpoint, but more recently I learned that the thoroughness of the physical exam can affect how much is billed. Some family physicians I'm working with on an offsite rotation say that the ED staff at their institution is notorious for performing, or perhaps just dictating, a complete exam to increase compensation. Has anyone else encountered this practice? Have any of the residents on this forum been asked to take part in this practice?

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[USCDiver]

Can you be more specific? Because some parts of the physical exam do not necessarily require formal testing based on chief complaint. I can document normal mental status and much of a neuro exam by watching the patient walk to the room and by taking a history.

 

[USCDiver]

Also, more to your point. Physical exam elements are usually not what causes a visit to be billed a lower level. It's usually elements in the history and ROS. And it's not like you can bill a Level 5 for a sprained ankle. The highest billing level possible is set based on chief compliant and diagnosis. It's just a matter of documenting enough to qualify for that level.

 

[AlienHand]

Can you be more specific? Because some parts of the physical exam do not necessarily require formal testing based on chief complaint. I can document normal mental status and much of a neuro exam by watching the patient walk to the room and by taking a history.

For example, a patient presents with shoulder pain and the physician dictates (among other things) that "bowel sounds were present, abdomen was soft, nontender, nondistended" and that "pupils are equal, round, and reactive." In this case, the abdominal and pupil exams were probably irrelevant and were not performed by the physician, so why bother including these parts of the exam in the dictation? Is this just a case of mindlessly documenting the same exam for every patient, or is the motivation legal or financial?

 

[Annette]

When I rotated throught the ED, I was told that I had to dictate all encounters as though they were level 5 (highest billing level). They would also send me messages to dictate cardiac rythms if the patient even got near a monitor so they could bill for it.

 

[southerndoc]

When I rotated throught the ED, I was told that I had to dictate all encounters as though they were level 5 (highest billing level). They would also send me messages to dictate cardiac rythms if the patient even got near a monitor so they could bill for it.

As you should. You should perform as thorough as an exam as possible and document it. You shouldn't make things up though. Billing is important, and no matter what specialty you are in, the harsh reality of not documenting properly will affect your wallet, your staffing availability, etc. by the amount of reimbursement.

 

[peksi]

An abdominal exam can certainly be warrented in a patient with shoulder pain.


Here are two examples:

19 you male presented with l shoulder pain 3 weeks after a sore throat and "viral illness" Abdominal exam reveals Mild RUQ tenderness, promting further study ( for me a fast exam) that reveals some IA free fluid and spenomegally. CT shows splenic hematoma with some extravisation post mono infection.

A 44 you female c/o R shoulder pain with movement, she works as a writer and is right handed. on exam a firm lymph node is noted, Abdominal exam reveals a firm nontender liver. Further testing is performed which identifies metastatic CA to liver and bone.

These are real life examples. I realize that you may have a differenct exposure in your situation, or may have specific valid examples of oyur own that prompted your IP. I've been tought in EM that we must expect the unexpected.

A thorough, though rapid PE exam should be performed, with focused details on pertinent positives and negatives related to the differencial diagnosis that is initiated with the patient history and is modified through your PE exam as well as diagnostic testing when warrented.


Paul

 

[AlienHand]

An abdominal exam can certainly be warrented in a patient with shoulder pain.


Here are two examples:

19 you male presented with l shoulder pain 3 weeks after a sore throat and "viral illness" Abdominal exam reveals Mild RUQ tenderness, promting further study ( for me a fast exam) that reveals some IA free fluid and spenomegally. CT shows splenic hematoma with some extravisation post mono infection.

A 44 you female c/o R shoulder pain with movement, she works as a writer and is right handed. on exam a firm lymph node is noted, Abdominal exam reveals a firm nontender liver. Further testing is performed which identifies metastatic CA to liver and bone.

These are real life examples. I realize that you may have a differenct exposure in your situation, or may have specific valid examples of oyur own that prompted your IP. I've been tought in EM that we must expect the unexpected.

A thorough, though rapid PE exam should be performed, with focused details on pertinent positives and negatives related to the differencial diagnosis that is initiated with the patient history and is modified through your PE exam as well as diagnostic testing when warrented.


Paul

Your examples make a case for performing a screening physical even on patients with seemingly minor complaints, and your first example is a reminder that irritation below the diaphragm may present as pain referred to the shoulder. However, my original question had more to do with the documentation of physical exam steps that were never performed in the first place, and whether residents or other physicians are under pressure - financial or otherwise - to take part in this practice.

 

[peksi]

However, my original question had more to do with the documentation of physical exam steps that were never performed in the first place, and whether residents or other physicians are under pressure - financial or otherwise - to take part in this practice.[/QUOTE]

Yup, I'm aware this was the intent of your original post, I just selected to provide examples of how aspects of the EM PE that on first glance 'may' seem unwarrented, can often be validly performed in light of the EM paradigm; "exluding the potential life threat, ALWAYS in patients presenting to the ED, rather than accepting what may be an apparrent diagnosis and truncating the PE.

There is no debate that documentation stating that one performed aspects of an exam that they did not is illegal and "upcoding".


Paul

 

[NinerNiner999]

During my ED rotation, I noticed that most, if not all, of the residents dictated a physical exam that was far more complete than the exam that was actually performed.

The fact you didn't see it performed, however, doesn't mean it was never done. Often times, I will push on a patient's belly at the same time I listen to their heart or chest. I'll test for EOM while I get their pulse. As was mentioned above, a neuro exam is very easily (and accurately) documented by simply watching movements. In a short 2 minutes or less it is easy to get a history and a complete physical exam that can be documented for level 5 billing. As was pointed out, though, the main billing points come from the history and review of systems (because it's known they take the most time and because the physical exam truthfully contributes very little to a patient's management and/or disposition).

 

[Annette]

As you should. You should perform as thorough as an exam as possible and document it. You shouldn't make things up though. Billing is important, and no matter what specialty you are in, the harsh reality of not documenting properly will affect your wallet, your staffing availability, etc. by the amount of reimbursement.

I certainly don't mind documenting and billing for what I have done, I just found it unreasonable to ask and document 9 ros on a sprained ankle. I also have a problem when the residents are pushed to do a "full exam." given less than enough time to perform the exam, but document that they did it anyway. I had a patient that I had to tell she needed her foot amputated because of an infection. She had a chronic infection in her foot, was seen in the ED for fever and not feeling well 2 days prior to being admitted with sepsis, and her chart read "extremeties- no cyanosis, no clubbing, no edema."

 

[southerndoc]

I certainly don't mind documenting and billing for what I have done, I just found it unreasonable to ask and document 9 ros on a sprained ankle. I also have a problem when the residents are pushed to do a "full exam." given less than enough time to perform the exam, but document that they did it anyway. I had a patient that I had to tell she needed her foot amputated because of an infection. She had a chronic infection in her foot, was seen in the ED for fever and not feeling well 2 days prior to being admitted with sepsis, and her chart read "extremeties- no cyanosis, no clubbing, no edema."

Some people just get in the habit of dictating the standard stuff. 5 patients later when they do their dictations, they might have forgotten certain specifics and just do their standard spill. When you are admitting patients, you are most likely capped at 6 patients (per RRC guidelines). The average EM attending sees 20+ patients in a 12-hour shift. So the person likely mixes exams together (which is why you should dictate or document as early as possible).

There is no reason you cannot document 9 review of systems on a sprained ankle. I do it everytime. Even for simple things. It only takes 3 questions per system to count the system as reviewed.

 

[Jeff698]

In a short 2 minutes or less it is easy to get a history and a complete physical exam that can be documented for level 5 billing.

Man, you've got to let this poor intern in on your tricks. That friggin' ROS KILLS me everytime. I refuse to dictate (knowingly anyway, SouthernDoc's point about autopilot dictation is a good one) something I didn't do. It seems when I'm in the biggest hurry is when my patients have the most positive ROS.

I just hate that damn ROS. Grrrr.

Take care,
Jeff

 

[NinerNiner999]

Man, you've got to let this poor intern in on your tricks. That friggin' ROS KILLS me everytime. I refuse to dictate (knowingly anyway, SouthernDoc's point about autopilot dictation is a good one) something I didn't do. It seems when I'm in the biggest hurry is when my patients have the most positive ROS.

I just hate that damn ROS. Grrrr.

Take care,
Jeff

I have gotten in the practice of performing my physical exam at the same time I ask questions. In addition to the cursory questions of fever, chills, nausea, vomiting, SOB, CP, ABD PAIN, dysuria, weight gain/loss, pain, I'll ask about any physical findings along the way (how long has your skin been yellow? is this rash new? what color is your stool?, etc.) It allows the time to cover the basic ROS and for more focused questions. No magic, really, just efficiency. If anything else creeps up, I'll ask more questions later once the initial workup has been started and I'm off the next patient. Don't forget, though, to sit down when you're done, tell the patient what you are going to test and why, and have them ask any questions - Press-Gainey likes that sort of stuff...

 

[The White Coat Investor]

My favorite phrase: All systems reviewed and pertinent only as mentioned in the history of present illness.

The only caveat is that you actually have to review them. Of course, a "review" is by definition a question about the organ system. I usually ask them two at a time...."Any fever or rashes?....Any problem seeing, hearing, or swallowing? Any headache or neck stiffness? Chest pain or shortness of breath? Abdominal pain, vomiting, or pain with urination? Any blood, muscle, or nerve problems? Any psychiatric problems?" Then they laugh and I move on to the physical exam.

You can be sure I ask much more involved questions regarding the important organ systems for that particular complaint, but in the ones that I just want to make sure I'm covered for a level 5 chart, that technically constitutes a complete review of systems. If you're not comfortable dictating "All systems reviewed...." you can always dictate something like:

Review of systems: No fever, rash, dysphagia, visual changes, neck pain, headache, dyspnea, chest pain, vomiting, abdominal pain, dysuria, swelling, joint aches, weakness, or psychiatric problems.

It only takes slightly longer. Just as one symptom per system constitues a review of systems (for billing purposes), one sign constitutes a system for physical exam. For example, a chest painer level 5 physical exam:
Vitals 120/87, 101 (Hell, you don't even need all of them, but they count as a system)
Gen: NAD
Skin: No diaphoresis
Neck: No JVD
CV: RRR
Pulm: CTAB
GI: nt
Lymph: Calves nt

I'm not saying you should always limit your exam or your review of systems to what you need for billing purposes, it does help you to be more efficient when you don't need any more information to take care of the patient properly.

That brings up my favorite social history too. Remember, a level 5 chart needs to have 2 of the 3 (Past Medical History, Family History, and Social History.) While PMHx is almost always important, family history rarely is, and social history only sometimes. So I always dictate as complete a PMHx as I can get, and then, unless important for the complaint, dictate something such as Social History: Married. That counts. If they want to write dumb rules for us to live by to get paid, we just have to learn what they are so we can play along too.

Some may think I'm skimping, but these techniques allow me more time to explore important things such as the HPI, and more time to think about the difficult cases I see, and more time to spend explaining things to patients. Trust me, your patient doesn't care about whether or not you get at least 10 systems reviewed.