Hi Jennifer,
One way to move from EPF to Detailed in the physical exam is called the 4x4 method.
Below is some information about the 4x4 method. Good Luck!
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 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 the physicians in PA 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.
Highmark Medicare Services nurse reviewers follow the guidelines for auditing E/M services that are provided by 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 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.