Question 1995 guidelines

wynonna

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Exam level: For EPF, we need 2-4 body/organ systems, Detailed: 5-7 body/organ systems, and Comprehensive: 8 or more body/organ systems. Must we have 2 points at least per body/organ system for 1995 guidelines? ie shouldn't there be at least 2 points per body/organ system to count as a system?

So for example: for cardiovascular to count as a system, documentation should have at least 2 elements, such as " no edema in extremities and normal rate and rhythm?" otherwise we would use 1997 guidelines to count individual points?
Thank you
 

cpc2007

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Hello,

The exam levels you have listed (2-4 for EPF, 5-7 for detailed, and 8 or more for comprehensive) appear to be from the AMA's guidelines for E/M services not from the CMS 1995 guidelines. I mention this only because the title of the post is 1995 guidelines and your question ultimately centers on how many bullet points per body/organ system is needed to "count" the organ system or body area according to the 1995 guidelines which come from CMS so I wanted to first clarify how the levels of exam are defined in the 1995 guidelines:
  • Problem Focused – A limited examination of the affected body area or organ system
  • Expanded Problem Focused – A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
  • Detailed – An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
  • Comprehensive – A general multi-system examination or complete examination of a single organ system (and other symptomatic or related body area(s) or organ system(s) – 1997 documentation guidelines)
Based on those definitions, problem focused would be examination of 1 body area or organ system (just the affected one). EPF and detailed both involve examination of 2-7 organ systems but different levels of detail in examination are required (limited exam of the affected organ system and at least one other symptomatic or related body area or organ system for EPF and extended exam of the affected body area or organ system and at least one other symptomatic or related body area or organ system for detailed). Comprehensive is 8 or more organ systems examined (or a complete exam of a single organ system which is more unusual to see).

To count an organ system, you only need one element of exam per organ system. So if you are trying to get 8 organ systems for comprehensive you might have vitals for constitutional (1 element), no wheezes for respiratory (1 element), A&O x3 for psych (1 element), etc., and if you get to 8 organ systems with just 1 element in each of those 8 organ systems, you have a comprehensive exam. The counting of bullet points is a more prevalent concept in the 1997 guidelines in terms of when to count an organ system or body area.

Where the number of elements per organ system may matter the most in 1995 guidelines is in distinguishing an EPF exam from a detailed exam. If they both require exam of 2-7 organ systems or body areas, the question becomes if you have 2-7 organ systems or body areas examined, how is "limited" vs "extended" exam to distinguish an EPF and a detailed exam defined? That is a question that CMS has not answered in black and white in the guidelines and part of why the more detailed 1997 guidelines were written. But my take and that of other skilled E/M auditors I have worked with is if there is only 1 bullet point per organ system or body area with 2-7, the exam is "limited" and is an EPF exam. If there are 2 or more bullet points documented per organ system or body area with 2-7, the exam is "extended" and would be detailed.

The organization you work for may have rules about which set of guidelines to use and how they interpret EPF vs. detailed in the 1995 guidelines (definitely a good discussion to have to ensure alignment among all coders or auditors on a team). But that has been my conclusion in the past and that of some of the organizations I have worked for. I hope that helps.

Kim
 

wynonna

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Thank you Kim. When I initially learned 1995 E&M Exam elements, my coding manager required 2 body areas or points per body or organ system to count. They were used to differentiate between problem focused, expanded problem focused, detailed and comprehensive/complete.
Would it be fair to say she was using the 1995 AMA guidelines?
Thank you
 
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