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EPF vs Detailed vs Comprehensive Exam

djnall

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Having trouble coding this case and need clarification on the exam part. The patient came in for recheck of the ears (seen 14 days earlier). During the exam, the physician reviews 5 body areas (neck, chest, abdomen, back and extremities) and 6 organ systems (eyes, ears/nose/throat/mouth, lungs, cardio, skin and neuro) and documents a short statement about each.

Since we have moderate decision making (Rx meds), would this be considered a level 4 (99214) since the exam is comprehensive.

Do it seem reasonable to do a comprehensive exam again, 14 days later?
 

pheeprice

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EM Exam

It seems odd that for only an ear recheck, the doctor would do such a thourough exam. However, according to the EM Tool on CMS, your exam does have 8 components, making it comprehensive. Guess you have a level 4 visit. ;)
 

allaire_s

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In the MDM part you have to meet 2 out of three parts. You can't have a Moderate MDM because the problem is established and the most you can give under the Number of DX and Management Options is 2 points for established worsening problem.

I disagree: MDM is Low.

Santa Allaire, CMC, CEMC
 

jdibble

True Blue
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I agree with Santa - the MDM is low, not Moderate. It would depend on the level of the History if you would be able to bill 99214 or if it would be 99213. Based on the presenting problem though and this being a follow up visit to a problem, I think a comprehensive exam was not needed - unless there was another issue.
 

Pam Brooks

True Blue
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I'm afraid I disagree with all of you. If the problem is stable or resolved, then the very best you can do, unless there was another problem addressed, is a 99212. Using MDM as the overarching criteria, you need two of the three MDM components to reach your level of MDM. With a stable or resolving problem, even with a prescription, the best you can get (I don't see any data points) is straightforward MDM. If it's worsening, then I would agree with a 99213, but only if the HPI or exam meet the level, based on medical necessity.

Unless other problems are present, a detailed or comprehensive exam might not meet medical necessity in this example. (mentioning them doesn't necessarily make them count-able). And just because organ systems or body areas are mentioned, the 95 Detailed guidelines require that at least one of those systems (preferably the ENT system, in this case) should be documented in detail. Six organ systems and five body areas for an ear recheck? I'd be concerned about giving credit for exam components that are unrelated to the chief complaint, and not linked to another presenting problem. I always use this example to make a point to my providers, "Why are you doing a gyne exam when the patient has a sore throat". Ususally, they've just forgotten to mention that the patient also has another GU-related complaint, but you want to point out that over-documentation to drive a higher code can be just as troublesome from a compliance perspective as not documenting at all.
 
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Milwaukee WI
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You do NOT have 8 systems

In the 1995 guidelines in order to get a comprehensive exam you must document examination of 8 of the following 12 organ systems. Please note that # 3 is considered ONE system (also # 12):

1. Constitutional
2. Eyes
3. Ears, nose, mouth, throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Skin
10. Neurologic
11. Psychiatric
12. Hematologic / lymphatic / immunological

For the 1995 comprehensive exam you can ONLY count organ systems. You cannot mix body areas and organ systems.

Hope that helps

F Tessa Bartels, CPC, CMEC
 

Jagadish

Guru
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"During the exam, the physician reviews 5 body areas (neck, chest, abdomen, back and extremities) and 6 organ systems (eyes, ears/nose/throat/mouth, lungs, cardio, skin and neuro)"

We have 8 systems here which qualifies the exam as comprehensive under 1995 guidelines.

Along with (6 systems) eyes, ears/nose/throat/mouth, lungs, cardio, skin and neuro; we can count exam elements from abdomen as GI and extremities as musculoskeletal provided we are not double dipping anywhere.

It would be better if the documented exam is posted for clear stand on this.
 
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