General Surgery Coding Alert

Physical exam element can point you to the better set.

You might boost your evaluation and management (E/M) code level -- or lose money for your surgeon's work -- depending on whether you follow the 1995 or 1997 E/M coding guidelines.

If you've ever wondered which set is better for your general surgeon's encounters, focusing on how to tally the physical exam documentation can be your key to success.

Choose More Systems or More Elements

The key differences in the 1995 and 1997 guidelines involve how you "count" the physical exam.

1995: Here's a breakdown of what you should document for each level of physical exam under the 1995 guidelines:

• Problem focused = 1 body system or area
• Expanded problem focused = 2-7 body systems or areas
• Detailed = 1 body system or area in greater detail and 1-6 brief system(s)
• Comprehensive = 8 or more body systems OR a complete single system exam.

1997: Contrast that to what you need to document for each physical exam level based on the 1997 guidelines:

• Problem focused = 1-5 bulleted elements in 1 or more organ systems
• Expanded problem focused = 6-11 bulleted elements in 1 or more organ systems
• Detailed = 12-17 bulleted elements in 2 or more organ systems
• Comprehensive = 18 or more bulleted elements from 9 or more systems or complete examination of a single system.

The 1995 version tends to be more multisystem oriented, which may make it more useful to the typical practice. Your surgeon gets credit for any comment related to any organ system or body area he examines, without requiring mention of specific elements.

In contrast, the 1997 guidelines include specific physical exam elements that the surgeon must address and document to count toward a higher E/M level. This system may be advantageous when the surgeon completes and documents a detailed exam of a single body system.

Lesson:Which set of guidelines you use depends on the type of exams at your practice, experts say.

"Some specialties will benefit from the use of 1995 rules, others will benefit from the use of the 1997," says Becky Boone, CPC, CUC, a certified reimbursement assistant in Columbia, Mo.

You might find the 1997 guidelines more useful if your surgeon tends to document lots of detailed elements focusing on fewer systems, for example. That's why it is so important to document all body areas examined and avoid using general notations such as "complete skin exam" (CSE) instead of specific annotations for each area examined. "The comment 'CSE' alone could not count as a detailed exam," says Pamela Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education in Georgetown, Texas.

One more thing: Aside from physical exam, the other two key components of an E/M encounter -- history and medical decision making -- essentially remain the same from 1995 to 1997 guidelines. The one exception is that the 1997 guidelines include "the status of at least three chronic or inactive conditions" in the definition of an extended history of present illness(HPI), while that language is absent from the 1995 guidelines.

Switch Between Cases, Not Within a Case

Good news for coders is that you don't have to choose one set of guidelines and use it every time you report an E/M service. Instead, you can use the set of guidelines that is most beneficial for a specific encounter.

According to Medicare instruction, "carriers and A/B Medicare Administrative Contractors [MACs] are to continue reviews using both the 1995 and 1997 documentation guidelines (whichever is more advantageous to the physician)." That means "physician practices are not restricted to using only one of the guidelines," says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver.

Plus: Private payers and Medicaid programs have uniformly adopted both the 1995 and 1997 guidelines as well.

Essential: The key is that you choose either the 1995 or the 1997 guidelines for a single encounter and stick with it. You can't mix the two guidelines for the same intervention to get a better result.

Try Your Hand at This Example

Look at the following case and decide which guidelines work to your advantage.

Case: Female, 54, presents complaining of left leg pain and swelling. The surgeon documents the following encounter:

• Weight: 187; Blood pressure: 140/68; Pulse: 72
• Neck: No jugular venous distention (JVD). No carotid bruits.
• Lungs: Clear
• Cardiac: Regular rate and rhythm (RRR). No murmur/gallop.
• Abdomen: Normal bowel sounds. No mass/bruit.
• Extremities: Pretibial edema of the left leg. Venous insufficiency and varicose veins of left leg evident upon standing examination. Ordered Doppler ultrasound to evaluate varicose veins for surgical treatment.

Solution: Based on the 1995 guidelines, this case earns a detailed exam -- detailed exam of the affected organ system (cardiovascular) and four other systems in brief. Using the 1997 general multi-system exam guidelines, however, the encounter earns an expanded problem focused level of service (six bulleted elements).

That means, the 1995 set is preferable in this case because the 1997 guidelines led to a lower-level "expanded problem-focused" exam, which brings less reimbursement than the higher-level "detailed" exam.