Wiki E&M, missing 1 element (Using 1997 DG's)

CoderinJax

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Hi all,
I would like your input in regards to the 1997 DG's for a Specialist in regards to the Physical Exam.

The Dr. nails every element needed for Comprehensive, except one. We'll use Neuro specialty for example where she's missing notating anything about the optic discs and posterior segments that are needed from the "Eyes" organ system.

Again, Dr. hits every other element needed for Comp, except that one. This is a REQUIREMENT, correct, in order to achieve the Comprehensive Exam? It's a shaded box on the 97 DG's, but I wanted someone else's opinion to ensure we are calculating correctly. (If one element is missing, it's going to drop down to Detailed.)

Thanks!
 
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I would interpret the guidelines the same way. They specify when you need 3 out of 7. So when they don't specify you only need so many, it means you need all.
 
I would interpret the guidelines the same way. They specify when you need 3 out of 7. So when they don't specify you only need so many, it means you need all.

Great point about the # (3 of the 7, etc) specifications. I'll let a few more weigh in, but I think we're on the right track. I don't want to be giving the physician a fit if it's something I should be cutting some slack on, but if it's a requirement, it's a requirement.
 
Yeah, if you're auditing using the Neurological Exam, and in order to get a Comprehensive Exam:

CMS states:
"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."

That means if: "Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)" element is missing, then the Exam is not Comprehensive. Most likely Detailed Exam instead.

When I audit and I come across a similar situation, I do look at other possible options for the exam tool. Could I use the General Multi-System Exam and get 9 organ systems with at least 2 exam elements each? Or another Specialty Exam. However, in my experience Neuro providers commonly does not deviate from their specialty exams; meaning if you are not getting the elements in the Neuro exam then you probably won't get the elements in other exams.

Hope that helps!
 
I agree with Pathos

If you miss one required bullet, then the "Comp" exam is out.

You don't have to stick with the 1997 DG, see what you get using the 1995 as they are easier to climb to a higher E/M level.

Having said that, the physician should never perform any part of an E/M just to meet specific guidelines. If it's not "Medically Necessary" it should be performed or counted if it is.
 
Excellent responses, thanks all!

Thank you guys for the replies! I felt like I knew what I was talking about but every single E&M is missing this one component for this Dr. to a degree so it made me question myself.

For those that code Neuro also, if there's a statement that states "fundi is benign" do you give credit towards the Eyes portion, assuming that comment can only be made with the Dr. using a scope and checking the optic disk area? Or do you stick that comment with where it says it under Neuro and mentions Fundi as an "E.g."?

Thank you all so much for your help!
 
Thank you guys for the replies! I felt like I knew what I was talking about but every single E&M is missing this one component for this Dr. to a degree so it made me question myself.

For those that code Neuro also, if there's a statement that states "fundi is benign" do you give credit towards the Eyes portion, assuming that comment can only be made with the Dr. using a scope and checking the optic disk area? Or do you stick that comment with where it says it under Neuro and mentions Fundi as an "E.g."?

Thank you all so much for your help!

No problem, that's why we are here!

This might just be a personal preference, however based on several conversations with Neurologists on the "Fundi benign" topic, I have gathered that statement can be counted towards either element, Eyes or the appropriate Cranial Nerve. As you are stating, the provider is using a fundoscopic tool to check the patient's discs and vessels. However, if the provider is documenting "discs" or "vessels" only, then Eyes would be credited and not the Cranial Nerve. Naturally, I would never credit both elements, as this would be double dipping.

That said, I could understand the argument of only crediting "Fundi" towards the Cranial Nerve, as the exam specifically states "fundi"; however based on my neurologists' arguments, "fundi benign" could still go either way. To make the documentation more bulletproof, consider educating the provider to include (if done of course) "vessels" and/or "optic discs" in their documentation, and exclusively use "fundi" towards the Cranial Nerve. This should remove any doubt what the provider is examining, and leave nothing up to chance in a future audit.

This is not based upon actual official guidelines, but rather the guidance of our clinical specialists (Neurologists).


Hope that is helpful!
 
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No problem, that's why we are here!

This might just be a personal preference, however based on several conversations with Neurologists on the "Fundi benign" topic, I have gathered that statement can be counted towards either element, Eyes or the appropriate Cranial Nerve. As you are stating, the provider is using a fundoscopic tool to check the patient's discs and vessels. However, if the provider is documenting "discs" or "vessels" only, then Eyes would be credited and not the Cranial Nerve. Naturally, I would never credit both elements, as this would be double dipping.

That said, I could understand the argument of only crediting "Fundi" towards the Cranial Nerve, as the exam specifically states "fundi"; however based on my neurologists' arguments, "fundi benign" could still go either way. To make the documentation more bulletproof, consider educating the provider to include (if done of course) "vessels" and/or "optic discs" in their documentation, and exclusively use "fundi" towards the Cranial Nerve. This should remove any doubt what the provider is examining, and leave nothing up to chance in a future audit.

This is not based upon actual official guidelines, but rather the guidance of our clinical specialists (Neurologists).


Hope that is helpful!

This was ESPECIALLY helpful and pretty much addresses exactly what was needed. I'll re-review the record to see if "fundi" is given towards Eye, if there is something then to cover the Neuro portion that mentions this as the "E.g.". If not, then I'm back to where I was at going down from Comp to Detailed as the P/E portion. THANK YOU so so much, this has been so insightful for me!
 
Additional question, Neuro 1997 DG's specific

Hello again!
I wanted to get an opinion using the 1997 DG's, Neuro specifically, on what all you would give credit for if you saw the statement in a record that stated "Memory and other cortical functions are grossly intact".

Per 97 Neuro, it mentions as required:

- Attention span and concentration
- Language (such as naming objects, repeating phrases, spontaneous speech)
- Fund of Knowledge (such as awareness of current events, past history, vocabulary)


If you saw the statement "Memory and other cortical functions are grossly intact", would that satisfy all 3 of the of those areas listed in bold above? Those 3 are listed as requirements and I can't find anything that breaks down what is acceptable and what is not, but this record isn't making it easy for me for sure. I've researched the best I can what is included in "cortical functions", but can't find anything definitive.

Thanks again for any insight!
 
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