Wiki detailed exam, 1995 guidelines

[JesseL]

Would the below be a detailed exam per 1995 guidelines? If going by this link http://www.ngsmedicare.com/ngs/wcm/...MOD=AJPERES&useDefaultText=0&useDefaultDesc=0

It says for detailed exam, "2 to 7 areas or systems (Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon)"

For the Eczema below I got neck, head and chest, that's 3 body areas, and it mentions there's itchy, erthematous papules, not just a check off list. Is that sufficient to be qualified as detailed exam? Help appreciated.


Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
- Patient is a 28 year old female who appears to be well developed and well nourished with good attention
to hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
- Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
- Above the Waist exam was performed on scalp (including hair), head (including face), neck, axilla, right
upper extremity, left upper extremity, hands, chest, abdomen, back, and breast.
Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek
Medical Decision Making: Eczema , problem worse, dermatitis skin care demonstrated in the office,
reviewed verbally, and handout given to patient
POC: Rx Triamcinolone 0.1% topical cream [triamcinolone 0.1% topical cream] apply BID on affected
areas , cetirizine 10 mg oral tablet [cetirizine 10 mg oral tablet] PO QD in AM , Elidel 1% topical cream
[pimecrolimus 1% topical cream] use twice daily
Recommendation is Explained medication should not be applied on the face unless directed., Explained
topical medication is for itching as needed. Patient should continue to keep skin well moisturized even
when asymptomatic., tested out protopic gel and elidel cream on split face for 10 mins. duing office visit.
along with vanicream moisturizer on face. pt likes the combination of elidel cream and vanicream better.
2. Xerosis
Dry located on face, left upper extremity and right upper extremity
Medical Decision Making: Xerosis , observe
POC: Recommendation is Can use a lighter lotion in the morning before getting dressed and a thicker
one such as vaseline in the evening after bath/shower., Develop habit of applying moisturizer at least
twice daily. Recommend unscented products such Vanicream., Dry skin instruction / handout given

 

[OCD_coder]

I would give credit for a detailed exam. The skin is the focus and he does a full body integumentary exam which is more extensive than an expanded problem focused exam that would be localized say just to the abdomen chest and back area.

 

[JesseL]

I would give credit for a detailed exam. The skin is the focus and he does a full body integumentary exam which is more extensive than an expanded problem focused exam that would be localized say just to the abdomen chest and back area.

Thanks for your response ocd_coder . He didn't do a full body though, he did an above the waist exam, I would think that's expanded problem focus if there's no mention of findings if I'm correct? But does the eczema note alone qualifies as a detailed exam since it describes what the Dr saw in those three body areas?

 

[OCD_coder]

Constitutional appears to be well developed and well nourished with good attention to hygiene. (3 bullets)
Psychiatric Note: The patient appears to be oriented by time, place and person.(3 bullets)
Skin Type:
- Patient has skin type IV (Beige with a Brown Tint). (2 bullets)
Exam Type:
- Above the Waist exam was performed on scalp (including hair), head (including face), neck, axilla, right upper extremity, left upper extremity, hands, chest, abdomen, back, and breast. (12 bullets)
Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek (positives)

An expanded problem focused would be as little as a couple of bullets. This provider performed a solid detailed exam and an exceptional example.

The key is not to use the checklists. Look at the information as items. "Expanded documentation.... requires more than checklists"

 

[JesseL]

Constitutional appears to be well developed and well nourished with good attention to hygiene. (3 bullets)
Psychiatric Note: The patient appears to be oriented by time, place and person.(3 bullets)
Skin Type:
- Patient has skin type IV (Beige with a Brown Tint). (2 bullets)
Exam Type:
- Above the Waist exam was performed on scalp (including hair), head (including face), neck, axilla, right upper extremity, left upper extremity, hands, chest, abdomen, back, and breast. (12 bullets)
Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek (positives)

An expanded problem focused would be as little as a couple of bullets. This provider performed a solid detailed exam and an exceptional example.

I'm a little confused, wouldn't general appearance, psych, and skin be one bullet each totaling 3 bullets?

And to my knowledge cms only recognizes head/face, neck, abdomen, chest + breast/ axillae, genital/groin/buttocks, back, and each extremities as body areas? I only get 7 bullets from the exam going by the check off list for body areas from the link i provided above.

 

[dtlandry67]

The original question stated they were using the 1995 guidelines. Therefore, this would be EPF with 3 Organ Systems documented- Constitutional, Psych and Skin. To break it down further and count bullets you would be using 1997. Also, for skin exam the provider is only listing the areas he examined but giving no further documentation to findings, I would recommend strengthening the skin documentation. If 1997 were used for Constitutional there would only be 1 bullet for general appearance (I don't believe I saw vitals, but if they were there it would then be 2 bullets).

 

[JesseL]

The original question stated they were using the 1995 guidelines. Therefore, this would be EPF with 3 Organ Systems documented- Constitutional, Psych and Skin. To break it down further and count bullets you would be using 1997. Also, for skin exam the provider is only listing the areas he examined but giving no further documentation to findings, I would recommend strengthening the skin documentation. If 1997 were used for Constitutional there would only be 1 bullet for general appearance (I don't believe I saw vitals, but if they were there it would then be 2 bullets).

But it says for detailed exam, "2 to 7 areas or systems (Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon)"

Wouldn't the note on the eczema be considered detailed since there's more than 2 areas looked at for it and abnormal findings were documented. Not a check list like the "exam type" note.

 

[dtlandry67]

By 1995 guidelines an EPF exam would be 2-4 (or 2-7 carrier dependent) Body Areas or organ systems. A Detailed exam would be 5-7 (or 2-7 Body areas or organ systems). A detailed exam is more of an extended exam vs a limited exam (EPF). This means for a Detailed exam you need to document several findings for both the affected area/system and at least one other related area/system. In this example your skin exam does have several findings, but does Constitution or Psych?

The guidelines are very vague when you take into consideration the 2-7 for both EPF and Detailed exam documentation. If you have to defend a physician's documentation in an audit this becomes tricky. When auditing we use the tool that breaks 1995 exam down into: PF 1 body area or system, EPF 2-4 systems including affected area(s), Detailed 5-7 systems including affected area(s) and Comprehensive 8 or more organ systems.

RACmonitor had an interesting article called the Top 10 Federal Audit Findings in E/M services and here was #7:
"The "4x4 Rule" and the conundrum of expanded problem focused (EPF) vs. detailed physical exams: Confusion surrounds these two specific exam levels because the 1995 and 1997 E/M Documentation Guidelines (DGs) are ambiguous for both EPF and detailed exams by stating both must contain "2-7 elements," specifying the EPF level requires a "limited" exam and detailed requires an "extended" exam. Both must address "the affected areas/systems and any other symptomatic or related areas/systems, up to 7." The similar definitions for "limited" and "extended" have caused provider misinterpretation and allowed for a predominant auditor finding of "insufficient PE documentation for a detailed level exam" such as for E/M codes 99203, 99214, 99221 and 99233. Survival Tips: Know the "4x4 rule;" it comprises four elements or items examined within four body areas or organ systems. For providers, the "4x4 rule" is a quick and uncomplicated method to avoid misinterpretation of these similar MR documentation levels. Compliance personnel should check with the Part B Carrier to ascertain applicability. Of note, federal auditors are tasked with referencing both sets of E/M DGs - 1995 and 1997 - adjudging each case being reviewed so the final assessment best benefits the provider".

I hope that helps you and I didn't just confuse the situation more!

 

[JesseL]

By 1995 guidelines an EPF exam would be 2-4 (or 2-7 carrier dependent) Body Areas or organ systems. A Detailed exam would be 5-7 (or 2-7 Body areas or organ systems). A detailed exam is more of an extended exam vs a limited exam (EPF). This means for a Detailed exam you need to document several findings for both the affected area/system and at least one other related area/system. In this example your skin exam does have several findings, but does Constitution or Psych?

The guidelines are very vague when you take into consideration the 2-7 for both EPF and Detailed exam documentation. If you have to defend a physician's documentation in an audit this becomes tricky. When auditing we use the tool that breaks 1995 exam down into: PF 1 body area or system, EPF 2-4 systems including affected area(s), Detailed 5-7 systems including affected area(s) and Comprehensive 8 or more organ systems.

RACmonitor had an interesting article called the Top 10 Federal Audit Findings in E/M services and here was #7:
"The "4x4 Rule" and the conundrum of expanded problem focused (EPF) vs. detailed physical exams: Confusion surrounds these two specific exam levels because the 1995 and 1997 E/M Documentation Guidelines (DGs) are ambiguous for both EPF and detailed exams by stating both must contain "2-7 elements," specifying the EPF level requires a "limited" exam and detailed requires an "extended" exam. Both must address "the affected areas/systems and any other symptomatic or related areas/systems, up to 7." The similar definitions for "limited" and "extended" have caused provider misinterpretation and allowed for a predominant auditor finding of "insufficient PE documentation for a detailed level exam" such as for E/M codes 99203, 99214, 99221 and 99233. Survival Tips: Know the "4x4 rule;" it comprises four elements or items examined within four body areas or organ systems. For providers, the "4x4 rule" is a quick and uncomplicated method to avoid misinterpretation of these similar MR documentation levels. Compliance personnel should check with the Part B Carrier to ascertain applicability. Of note, federal auditors are tasked with referencing both sets of E/M DGs - 1995 and 1997 - adjudging each case being reviewed so the final assessment best benefits the provider".

I hope that helps you and I didn't just confuse the situation more!

Sooo you're saying I need to get 4 bullets from body areas and 4 from organ systems to get detailed exam for 95 guidelines?

 

[JesseL]

Constitutional appears to be well developed and well nourished with good attention to hygiene. (3 bullets)
Psychiatric Note: The patient appears to be oriented by time, place and person.(3 bullets)
Skin Type:
- Patient has skin type IV (Beige with a Brown Tint). (2 bullets)
Exam Type:
- Above the Waist exam was performed on scalp (including hair), head (including face), neck, axilla, right upper extremity, left upper extremity, hands, chest, abdomen, back, and breast. (12 bullets)
Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek (positives)

An expanded problem focused would be as little as a couple of bullets. This provider performed a solid detailed exam and an exceptional example.

The key is not to use the checklists. Look at the information as items. "Expanded documentation.... requires more than checklists"

So the note below qualifies as detailed/extended exam because its within 2-7 body areas with findings (erythematous papules, itching) and not just a check list?

Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek (positives)

 

[dtlandry67]

No, I am not saying that. Here is an example for a Detailed exam by 1995 guidelines: We will use an abdominal pain example

Vital signs: 3 are listed and the documentation states "well nourished female in mild pain. (Constitutional- organ system)
Eyes: PERRLA (Eyes- organ system)
Heart is normal rhythm, no mumurs (Cardiovascular- organ system)
Lungs are clear to auscultation bilat, no crackles, rubs or wheezing (Resp- organ systsm)
Abdomen soft, normal bowel sounds, no hepatosplenomegaly (Abdomen- organ system
Skin reveals no rashes or lesions (Skin- organ system)

This has 6 organ systems documented, Detailed level

Now lets assume all of the above is the same except for Abdomen which only has "non-distended" documented. Documenting it this way wouldn't strongly support an organ system as this finding can be seen and the pt not necessarily examined so it would support a body area more; but it would still be Detailed because it would be 5 organ systems including the affected body area (in this example the abdomen).

Hope that helps!

 

[JesseL]

No, I am not saying that. Here is an example for a Detailed exam by 1995 guidelines: We will use an abdominal pain example

Vital signs: 3 are listed and the documentation states "well nourished female in mild pain. (Constitutional- organ system)
Eyes: PERRLA (Eyes- organ system)
Heart is normal rhythm, no mumurs (Cardiovascular- organ system)
Lungs are clear to auscultation bilat, no crackles, rubs or wheezing (Resp- organ systsm)
Abdomen soft, normal bowel sounds, no hepatosplenomegaly (Abdomen- organ system
Skin reveals no rashes or lesions (Skin- organ system)

This has 6 organ systems documented, Detailed level

Now lets assume all of the above is the same except for Abdomen which only has "non-distended" documented. Documenting it this way wouldn't strongly support an organ system as this finding can be seen and the pt not necessarily examined so it would support a body area more; but it would still be Detailed because it would be 5 organ systems including the affected body area (in this example the abdomen).

Hope that helps!

What if we're counting only body areas?

I believe we can only count one or the other (body area or organ systems) not combine them?

I'm asking because I work for dermatology so we deal with mainly body areas. I could hardly make use of the organ systems part because a dermatologist would hardly ever take vitals and such.

I thought the eczema note would suffice because it mentions 3 body areas, neck, breast, head/face. Would saying "erythematous papules and itching" located in these areas suffice as detailed/extended exam?

Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek (positives)

 

[dtlandry67]

With 1995 guidelines you can combine organ systems and body areas for all levels except Comprehensive which requires 8 or more organ systems (A problem focused exam is only 1 ba or os).

If you are going to use 1995 guidelines and only count skin then you will never get it to Detailed because you will only have 1 Organ system if there is no further exam documented.

If you use 1997 guidelines instead, then you can get credit for the elements you are listing. But remember if you use 1997 you will get 10 points if you document all areas for the skin exam (Head, neck, chest, back, abdomen, genitalia, right upper extremity, left upper ext, right lower ext and left lower ext). You still would need 12 elements for a detailed skin exam which is why the vitals and general appearance of the pt could count for 2 more elements to get you to twelve.

Bottom line, your exam documentation is going to have to be stronger to support detailed.

 

[dtlandry67]

Also, I understand how you are looking at the body areas and trying to count them with 1995 guidelines, but an auditor can say that they are all areas of skin (the organ system) and the provider did a skin exam. Your skin our largest organ.

Perhaps reviewing CMS E/M documentation guidelines for the skin exam with your physicians may help you create a stronger exam that can't be questioned by an outside audit? I'm just afraid the exam documentation you are using now will not be able to be successfully argued against a RAC auditor.

I worked Derm for years in the back office and we always took vitals (especially after someone finishes a procedure, their bp starts dropping back down and they pass out)

 

[JesseL]

Also, I understand how you are looking at the body areas and trying to count them with 1995 guidelines, but an auditor can say that they are all areas of skin (the organ system) and the provider did a skin exam. Your skin our largest organ.

Perhaps reviewing CMS E/M documentation guidelines for the skin exam with your physicians may help you create a stronger exam that can't be questioned by an outside audit? I'm just afraid the exam documentation you are using now will not be able to be successfully argued against a RAC auditor.

I worked Derm for years in the back office and we always took vitals (especially after someone finishes a procedure, their bp starts dropping back down and they pass out)

Yeaa it'd be nice if our practice took vitals and give me something extra to work with. Our practice only do minor procedures so I guess that's why they never take vitals. I've seen 3 other dermatologist as a patient myself and none of them have ever taken my vitals though..

Aside from skin, the only thing I can use from the organ systems list from the documentation I posted is constitutional and psych but I don't think they're detailed enough to get me detailed exam?