ED Charting and Coding: Physical Exam (PE)

“What do I see, hear, and smell when I walk into the room?” While the oral boards challenge you to perform the physical exam in a certain way, the day to day examination of patients can vary dramatically. Centers for Medicare and Medicaid Services (CMS), however, has physical exam guidelines for billing that conform to neither the exam you learned as a medical student nor the one you’ve refined as a resident. These disparities between what you do and how you’re asked to document it can lead to charts that are frequently down-coded or at risk if audited. The following discussion tries to unravel some of these twisted regulations and will provide tips and tricks on how to improve your physical exam documentation for coding and billing.

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2016-11-17T12:00:04-07:00

November 9th, 2016 | Administrative

By: Ted Fan, MD, Joshua Burkhardt, MD and Bjorn Watsjold, MD |Editors: Allison Trop, MD

ED Charting and Coding: Review of Systems

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.”

This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

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2019-04-06T00:47:13-07:00

November 2nd, 2016 | Administrative

By: Bjorn Watsjold, MD, Sean Dyer, MD and Joshua Burkhardt, MD |Editors: Allison Trop, MD

ED Charting and Coding: History of Present Illness & Past Medical, Family, Social History

Remember the “OPQRST” mnemonic? It stands for Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing. Not only can it guide your history taking, but charting these descriptors also ensures you can code at an appropriate level. The patient’s history is the first example of the balance between essential information and over-documentation. It should be comprehensive, yet be chief-complaint focused [1]. Below, we outline the components of a thorough and billable history.

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2016-11-28T13:40:50-07:00

September 5th, 2016 | Administrative

By: Sean Dyer, MD, Joshua Burkhardt, MD, Bjorn Watsjold, MD and Ted Fan, MD |Editors: Allison Trop, MD

PV Card: Introduction to ED Charting and Coding

What makes a good chart? How do you write a good chart quickly? How about a good, efficient, billable chart? On average, residents and practicing physicians report they did not receive adequate training in charting and coding^1–3 and resident charts are more often down-coded due to documentation failures than those of attendings and PAs.⁴ Thankfully, resident education in charting has improved over the past 15 years,⁵ and a little learning goes a long way to improve confidence⁶ and competence.⁷

In the spirit of #FOAMed, we would like to provide some pearls and pitfalls for EM documentation, starting with a PV card that addresses the basic elements of coding a chart. We hope it’s a handy on-shift reference.

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2017-08-01T19:52:43-07:00