“Hammertoe” Is Not An Exam Finding

The 2021 Evaluation and Management (E&M) changes only apply to office and other outpatient evaluation and management services. Those changes do not apply to any other E&M type.  Therefore, one should still quantify and consider bullets of exam when choosing E&M levels for nursing home encounters, hospital encounters, home visits and other E&M types. For these E&Ms it is important that one clearly documents exam elements and does not confuse them as assessments.

Exam finding documentation should use language that describes the finding rather than with language that describes the diagnosis that resulted from the exam finding.  Most auditors are not clinicians.  It is not wise to rely on an auditor’s ability to differentiate between an exam finding and an assessment when quantifying exam bullets to determine an appropriate E&M level.

Here are two examples:

Exam:  Right second toe is dorsiflexed at the metatarsophalangeal joint, plantarflexed at the proximal interphalangeal joint and dorsiflexed at the distal interphalangeal joint.

Diagnosis: Right second hammertoe

In this example it would be inappropriate to document “right second hammertoe” as an exam finding because “right second hammertoe” is actually a diagnosis made as a result of an exam finding.  If one documents “right second hammertoe” in the exam section of an E&M progress note, an auditor may not consider that an exam bullet when determining the E&M level.

Exam:  Right fifth metatarsal is deviated laterally with the fifth toe deviated medially with the fifth toe laterally rotated and bony prominence of the fifth metatarsal head present laterally.

Diagnosis: Right tailor bunion

In this example it would be inappropriate to document “right tailor bunion” as an exam finding because “right tailor bunion” is actually a diagnosis that was made as a result of an exam finding.  If one documents “right tailor bunion in the exam section of an E&M progress note, an auditor may not consider that an exam bullet when determining the E&M level.

Dr. Lehrman operates Lehrman Consulting, LLC, is a consultant to the APMA Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Certified Professional Coder. Follow him on Twitter @DrLehrman.