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The Driving Parts of E/M Level Selection: Part 2

Part 2 of this three-part series provides an in-depth look at the exam component.

By G. John Verhovshek, MA, CPC
In this three-part series on the driving components of level selection for the majority of evaluation and management (E/M) services, we discuss the history, examination, and medical decision-making components. In May’s issue of Coding Edge, we featured part 1, which provided an in-depth explanation of the history component. This month, part 2, we’ll focus on the exam component.

Exam Levels

An E/M service’s exam component is, as the name implies, the patient’s examination by the physician. CPT® identifies four “levels” of exam, depending on the extent of the physician work:

  • Problem-focused
  • Expanded problem-focused
  • Detailed
  • Comprehensive

The 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, jointly developed by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA), define differently the specific elements that determine the exam level. The downfall of the 1995 guidelines is specific acknowledgment of the normal work and documentation of many specialists is not included. The downfall of the 1997 guidelines is too many specific documentation elements are required.

1995 and 1997 Documentation Guidelines

Currently, Medicare allows physicians and providers to use the set of guidelines they prefer most. CMS audits according to whichever set of guidelines are most beneficial to the physician or provider in a particular case.
Resource tip: You can access both 1995 and 1997 guidelines on the CMS website.
Remember, you may not “mix and match” the 1995 and 1997 guidelines. If you select the 1997 guidelines for an E/M service’s exam component you should use the same guidelines to determine the level of history and in medical decision making. Consider your specialty’s nature, and the typical documentation the physician generates, to determine which guidelines set to use. Both 1995 and 1997 guidelines recognize the same body areas, including:

  • Head, including the face
  • Neck
  • Chest, including the breast and axillae
  • Abdomen
  • Genitalia, groin, and buttocks
  • Back, including spine
  • Each extremity

Both guidelines recognize the same organ systems, including:

  • Constitutional (for example, the patient’s
  • General appearance and vital signs)
  • Eyes
  • Ears nose, mouth, and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic, lymphatic, and immunologic

Both 1995 and 1997 guidelines require the provider to elaborate on abnormal findings and describe unexpected findings. Both guidelines also allow a brief note of “negative” or “normal” to document normal findings or unaffected areas or systems.
As noted, however, the 1995 and 1997 guidelines define the four levels of exam (problem-focused, expanded problem-focused, detailed, and comprehensive) differently. The 1995 guidelines define the levels of exam as follows:
Problem Focused—a limited examination of the affected body area or organ system (that is, a limited exam on only one affected body area or organ system)
Expanded Problem Focused—a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (that is, a limited exam of at least two body areas or organ systems)
Detailed—an extended examination of the affected body area(s) and other symptomatic or related organ system(s) (that is, an extended examination of at least two body areas or organ systems)
Comprehensive—a general multi-system examination or complete single-organ system examination (The medical record for a general multi-system examination should include findings about eight or more of the 12 organ systems)
For example, a patient presents with a complaint of wheezing, cough, and fever. The physician performs the following exam:

GENERAL: 12-year-old, age appropriate, appears in no acute distress. A&O x 3, EARS: TMs: Gray, translucent; light reflex and bony landmarks present bilaterally. External canals normal to examination, NOSE/SINUS: No flaring of nares. Septum: Midline and patent bilaterally. Mucosa: Pink and moist. Clear discharge from the nose, but no sinus tenderness noted to palpation. THROAT/MOUTH: Buccal mucosa: Pink and moist. No lesions. Teeth: Good repair. Tongue: Midline without fibrillation. Uvula: Midline with elevation of soft palate. Gag reflex: Intact. Pharynx: Slightly erythematous. 2+ swelling with postnasal drip noted. Gums: Pink and intact. NECK: Supple without lymphadenopathy. CHEST/LUNGS: Scattered wheezing bilaterally. No rales or rhonchi. No accessory muscle use or retracting. HEART: RRR without murmur, rub, or gallop. ABDOMEN: Soft, nontender, bowel sounds to all four quadrants.

According to 1995 guidelines, the documentation supports a detailed exam because the physician performs an extended exam of two to seven body areas/systems.

1995’s Gray Areas Can Confuse Level Determination

The 1995 guidelines, although generally clear, contain two gray areas that may complicate your ability to determine the exam level:

  • An expanded problem-focused exam and a detailed exam both require examination of at least two body areas and/or organ systems; the expanded problem-focus level requires that these exams are “limited,” whereas the detailed level requires these exams are “extended.” The terms limited and extended are not defined specifically.
  • The definition of a comprehensive single system exam is defined only as “complete.” The term complete is also not defined specifically.

1997 Draws a Line Between Black and White

The 1997 guidelines eliminate this subjectivity by exactly specifying—using bulleted items—the exam requirement for a particular body area or organ system. These requirements provide objective, exact criteria from which to measure physician documentation against. Although too lengthy to list here, detailed list of bulleted exam requirements may be found on pages 13-42 of the documentation guidelines.
When using 1997 guidelines, the physician may select from the general multi-system exam or any of the single organ system exams. The coder must review each documented element to determine which single-organ system exam is the most appropriate E/M service level selection. For instance, a problem-focused, general multi-system examination requires the documentation of at least one bullet. For an expanded problem-focused exam, at least six bullets must be documented. For a detailed examination, there should be documentation to support two bullets in at least six organ systems or body areas, or a total of 12 bullets in two or more organ systems or body areas.
For example, a physician performs the following exam for a patient with rheumatoid arthritis:

EXAM: Hand deformities persist with synovial fullness 2nd, 3rd, and 5th MCP joint of the right hand, 2nd and 3rd MCP joint of the left hand. No definite synovitis over the IP joints or the wrists, elbows, knees, or ankles. Range of motion of the knees is 5-85 degrees with 1+ crepitus, shoulder motion limited with 80 degrees abduction, 120 degrees elevation but in the anatomic position flexion and extension appear normal.

According to the musculoskeletal exam template in the 1997 guidelines, the physician performed an expanded problem-focused exam (at least six bulleted items from the musculoskeletal examination documented).
Physicians should focus on the medical necessity of an exam, and should never document “just one more bullet” to achieve a higher service level.
“The type (general multi-system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s),” according to the 1997 guidelines.
For instance, it might be considered necessary to perform a comprehensive exam when a new patient presents, but medically unnecessary to repeat a complete review on every follow-up.

More to Come

If you have trouble differentiating between the review of systems (ROS) elements and the exam elements, you are not alone. To help you make a determination using just one question, we’ve included the sidebar “Distinguish ROS from Exam Element” in this issue.
Coming up in this three part series is the medical decision-making component. When this article trilogy is complete, you will have the basic information needed to choose E/M service levels with confidence, and also to audit E/M claims for accuracy and consistency.

Evaluation and Management – CEMC

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