Surgeons as Educators A Guide for Academic Development and Teaching Excellence

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requirements (the same as C5/N5): CC, four HPI bullets, ten ROS, and three (one
each) of PMFShx. Some providers choose not to remember the table and instead
use the last sentence in all of their notes to ensure they meet all history billing
requirements.

Pillar 2: PE (Physical Exam) (Fig. 23.3)
Physical exam requirements for a level 5 visit are very straightforward. Recall
that there are two systems: 1995 and 1997. Surgeons for the most part are better
served utilizing the 1995 system. If you prefer to do more work, feel free to look up
the 1997 system on your own (a 1997 level 5 PE exam requires more than double
the bullets of the 1995 system of eight bullets). The organ systems to choose from
in the 1995 system include constitutional, eyes, ENTM, respiratory, GI, GU, mus-
culoskeletal, integument, endocrine, CV, heme/lymph, allergy/immunologic, neuro-
logic, and psychologic. Pick eight of these symptoms and describe one physical
finding. Of course, a more detailed physical exam is often required for optimum
patient care. To optimize billing, a very reasonable approach is to do an eight- system
exam on all patients.

Summary of Pillars 1 and 2 (and a Fibonacci Sequence... Not Really)
C5 Note = CC + 4 HPI + 10 ROS + 1 PMhx +1 + PFhx + 1 PShx + 8 PE = {5 = C,
4, 10, 1, 1, 1, 8}

Pillar 3: MDM (Medical Decision-Making) (Fig. 23.4)
MDM is the most complex part of billing. Good thing you have already mastered
the two other pillars. The level billable from MDM is derived from the second
highest- scored section available. The three categories are DDR, diagnoses, data,

PHYSICAL EXAM

Consults and NP

Level 1

Single 1-3

0-2

1-31-3

4+

4+

1 element

8 systems

1 element

8 systems

1-3

1-3

1-3 4+

4+

1 element

8 systems

SingleAffected

SingleAffected

SingleAffected

SingleAffected

Single

SingleAffected

SingleAffected

SingleAffected

SingleAffected

Level 2 Level 3 Level 4 Level 5

Level 1 Level 2 Level 3 Level 4 Level 5

Established Patient

Body Areas

Head, including faceNeck

Chest, incl. breast & axillAbdemen a

Genitalia, groin, buttacksBack, including spine

Each Extremity

ConstitutionalEyes

ENTMRespiratory

GIGU

MSIntegument

EndocrineCV

Hemat/LymphAllerg/Immun

Psychologic

PrExpanded Problem Focused:oblem Focused: Limited exam of affected body area or organ system Limited exam of affected body area or organ system and

other symptomatic or related organ system(s)Detailed: Extended exam of affected body area(s) and other symptomatic

or related organ system(s)Comprehensive: A general muti-system exam or complete exam of a single organ system

Limited = 1-3 elements

ALWAYS DEFAULT TO THE LOWEST LEVEL OF SERVICE DOCUMENTED

Extended = >3 elements

Organ Systems

Fig. 23.3 Physical exam billing rules

T.S. Köhler