Does anyone understand the verbiage.. "Clinical inference overrides 4 X 4 tool" given by Novitas Solutions in their E/M auditing webinar? It is also referenced in a FAQ...
10. What is the 4 x 4 method for determining if an examination is scored as an expanded problem focused or detailed?
Under the 1995 guidelines both the expanded problem focused examination and the detailed examination provide for the examination of up to 7 systems or 7 body areas. This has led to variability in reviews utilizing the 95 guidelines, and requiring an interpretation for proper and consistent implementation of the evaluation and management (E/M) guidelines. By providing a tool we call 4X4 (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment) our reviewers and physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity. This tool is consistent with the way medicine is practiced, as confirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to Physical Examination by Barbara Bates, M.D. And, it is a tool to reduce reviewer variability.
Novitas Solutions nurse reviewers follow the guidelines for auditing E/M services that are provided by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA). This includes consideration of both the 1995 and 1997 guidelines, with the utilization of the guidelines that are most beneficial to the physician. We also instruct our nurse reviewers to use their clinical knowledge while reviewing the medical record documentation to determine the correct and appropriate level of care. Clinical inference overrides the 4 x 4 tool. It provides for an individual consideration, and makes the review of all services (including E/M examinations) fairer to the physician. Clinical inference is in keeping with the CMS current instructions for reviewing all medical records. Again, our reviewers utilize either the 95 or the 97 guidelines when reviewing E/M services, and utilize the guidelines that benefit the provider.
With all of this said, our reviewers utilize one of the following when making a determination on whether an examination is expanded problem focused or detailed. The method chosen must be the one that is most beneficial to the physician.
? 1997 E&M examination guidelines,
? 1995 E&M examination guidelines utilizing the 4 x 4 tool, or
? 1995 E&M examination guidelines utilizing clinical inference.
Date Posted: 10/05/2009, Date Revised: 11/15/2013
10. What is the 4 x 4 method for determining if an examination is scored as an expanded problem focused or detailed?
Under the 1995 guidelines both the expanded problem focused examination and the detailed examination provide for the examination of up to 7 systems or 7 body areas. This has led to variability in reviews utilizing the 95 guidelines, and requiring an interpretation for proper and consistent implementation of the evaluation and management (E/M) guidelines. By providing a tool we call 4X4 (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment) our reviewers and physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity. This tool is consistent with the way medicine is practiced, as confirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to Physical Examination by Barbara Bates, M.D. And, it is a tool to reduce reviewer variability.
Novitas Solutions nurse reviewers follow the guidelines for auditing E/M services that are provided by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA). This includes consideration of both the 1995 and 1997 guidelines, with the utilization of the guidelines that are most beneficial to the physician. We also instruct our nurse reviewers to use their clinical knowledge while reviewing the medical record documentation to determine the correct and appropriate level of care. Clinical inference overrides the 4 x 4 tool. It provides for an individual consideration, and makes the review of all services (including E/M examinations) fairer to the physician. Clinical inference is in keeping with the CMS current instructions for reviewing all medical records. Again, our reviewers utilize either the 95 or the 97 guidelines when reviewing E/M services, and utilize the guidelines that benefit the provider.
With all of this said, our reviewers utilize one of the following when making a determination on whether an examination is expanded problem focused or detailed. The method chosen must be the one that is most beneficial to the physician.
? 1997 E&M examination guidelines,
? 1995 E&M examination guidelines utilizing the 4 x 4 tool, or
? 1995 E&M examination guidelines utilizing clinical inference.
Date Posted: 10/05/2009, Date Revised: 11/15/2013