Wiki Comprehensive Organ/System Exam 1997 Guidelines

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nicoleysmith

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Can anyone further explain how one can receive a comprehensive exam on a single organ system? I am using the CMS 1997 guidelines, but I don't understand how it's different except when all the bullets are performed in a single are hit?

page 16 of the 1997 guidelines says:

Problem Focused: 1-5 bullets
Expanded Problem Focused: 6 bullets
Detailed: (except eye and psych) 12 bullets
Comprehensive: all elements in a box.

If a provider is examining an injured shoulder, they are't necessarily going to examine the patient's gait and station/digits and nails. So if they do everything else in the box, that's 4 bullets and falls under problem focused, correct? Even with vitals, that's still 5 bullets so problem focused? Or they performed all 4 elements of the upper limb exam and so it's comprehensive?

Please and thank you!
 
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When using the E/M 1997 exam guidelines, either all of the components are examined and documented, or the exam bumps down to the next level depending on what was examined and documented.

For example, if not all of the shaded elements in the boxes were examined, as outlined in the 1997 exam guidelines; then if there are enough exam bullets examined and documented, the exam level will qualify for that level.
If the provider examined 13 exam bullets, but did not do enough to get all of the shaded elements in the boxes, then the exam would default to a Detailed exam.
If the provider examined 9 organ systems with at least 2 exam elements (bullets) in each, then that would qualify for a Comprehensive Exam. This is often a pretty comprehensive exam and usually a head to toe exam.

Don't forget about Medical necessity (which you are briefly touching on as well). Does the provider REALLY need to examine the required elements, or are they just doing it to hit the highest E/M level possible?

I used to educate providers on E/M coding, and the Musculoskeletal Comprehensive exam was always a tricky one for our Orthopedists. Then again, keep in mind that these high levels are reserved for the more severe cases, and probably shouldn't be the standard exam for every patient and every visit.


Hope this guides you somewhat!
 
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For the General Multi-system Exam:
  • Comprehensive Examination – should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected

For the Specialty/Single organ system Exam:
  • Comprehensive Examination – should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected.
  • Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border

To me that reads concerning the Single Organ System:
  • Do the exam as appropriate/medically necessary
  • If all of the elements in a box with a shaded border, plus at least one elements in a box with an unshaded border have been examined and documented, then that's should qualify for a Comprehensive Exam (depending on the specialty).
We as coders don't determine medical necessity, however we can question the validity of the medical necessity of a chart in order to protect its integrity and in extension, the integrity of the provider/clinic/etc. Most clinics/health systems have a policy in place for medical necessity, and might be something to bring up to your supervisor/manager/compliance officer.

As far as I am aware, the provider specialty doesn't have to dictate which specialty exam they are using. If a Family Doc is doing an appropriate extensive exam on a patient which could qualify for one of the specialty exams, then I don't see anything unethical about that practice. The specialty exams are there to capture when a provider is performing an extensive exam on a single organ system, and is giving them credit where credit is due. While the General Exam maxes out at 2 for the Neuro exam, the Neuro specialty exam can credit the provider a whole lot more (again, as appropriate).


Hope this clear up a few things :)
 
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When you are referring to the shaded boxes, are you referring to the specialty exam bullet list? Because I don't see any shaded or unshaded boxes on the normal sheet, only shaded borders on the specialist exams starting on page 18. Am I missing something?

I didn't think a coder was qualified to determine medical necessity. I was under the impression that if the provider does something, they believe it is medically necessary - I just go off what was documented in the encounter note.

Just because a normal family practice provider only treats a skin issue doesn't mean we can use that, correct? Only a dermatologist can use the specialty exam.

I am seeing contradictions in the levels the providers are requesting compared to their notes and I want to make sure I am using the guidelines correctly before I make any adjustments.
 
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