Wiki 1997 Exam Bullets

thelton

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I audit our GYN and Neuro docs using the 1997 specialty exams. I need an opinion....I have researched this and cannot find an answer. If a "bullet" cannot be performed in the exam due to circumstances beyond provider control, should they be penalized and not allowed an otherwise comprehensive exam? For example, a GYN patient has had the uterus removed or the neuro patient that is confined to a wheelchair and the provider cannot assess gait and station? I know if a ROS is unobtainable and the reason is documented, the provider isn't penalized. But....I have not been able to find anything to support this for the 1997 exam. I agree with my physicians when they state they should not be down-coded from a justified, medically necessary 99205 to a 99203 because of something beyond their control. I would just like to have something (preferably in writing) that would hold up in case of an audit. I could not find anything on my MACs website (Novitas). The documentation definitely would not meet a comprehensive exam using the 1995 guidelines, especially Neuro, and I don't want them documenting organ systems just to get to a comprehensive exam (i.e. ENT, GI, GU for Neuro). Opinions? Would it be sufficient to document "uterus surgically absent" or "patient confined to wheelchair - unable to assess gait and station"?
 
I have never seen anything in writing stating that you can give credit for exam components that have not been performed, and personally I believe it would not be appropriate to do so - if you started such a practice, it could theoretically have no limits and a provider could get full exam credit for a patient who refused to be examined, for example. As you note, the CMS guidelines do only specify an exception for ROS but not for any of the other components of an E&M code. I do not consider this 'penalizing' the physician - as illogical and outdated as the E&M rules and guidelines may seem, they are what they are. The coding and RVU system is not designed to capture revenue for every single element of provider work, but rather is set up to report general categories of services which in aggregate should accurately reflect the overall work the providers do. The there will be individual cases where the rules may work to the financial advantage or to the disadvantage of the provider, but these should average out over time.
 
I have never seen anything in writing stating that you can give credit for exam components that have not been performed, and personally I believe it would not be appropriate to do so - if you started such a practice, it could theoretically have no limits and a provider could get full exam credit for a patient who refused to be examined, for example.

Well, yes, but no exam is no exam. Trying to get credit for it would be straight up fraud. For a general exam, it would not be appropriate to count that organ system. In a specialty exam, if it's that one bullet that's keeping you back--such as the example of gait and station for a patient in a wheelchair--if it's documented that that one piece can't be done, I think most auditors would still allow credit for a comprehensive exam. Also, under the 1995 rules "complete single organ system" counts as a comprehensive exam...which is extremely vague, and hence why we have the specialty exams. However, if you're getting all of the other elements in the 1997 exam? Hard to argue it's not comprehensive.

As to the original poster's particular situation, you only need 7 bullets from the GU box. If you skip the uterus, there's still 10 other things the provider can check to achieve a comprehensive exam. If you're using a template in the EMR, I would recommend adding all of the choices, and they can ignore the ones that don't apply.
 
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