Wiki Exam documentation

Create Wiki
L

LauraLight

Contributor
Messages
12
Location
Rock Hill, SC
Best answers
0
It is my understanding that an Exam is no longer used for E/M leveling. Does this mean the provider does not have to document it at all? I've been told that because it states "history and/or medically necessary" exam, this means it's up to the provider whether they want to do one or not. I'm under the firm opinion that (at least for CMS) it is till required documentation, as per MLN matters article referenced here. https://www.cms.gov/Outreach-and-Ed...ips/medicare-provider-compliance-tips.html#EM
...Can anyone confirm?
 
MLN refers directly to the CPT document for details of requirements and the CPT document does not require an exam if not medically necessary:

"►E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes.◄ "

I am not aware of ANY guidance AT ALL that says that documentation of a physical exam is necessary for any E&M encounter.
Not documenting a physical exam is -usually- mediocre medicine, but an exam is not an integral component of an E&M encounter anymore, and it is not the job of a coder or auditor to assess when an physical exam is medically necessary.
 
Thank you for your reply. I have heard it both ways, and I suppose I am in the camp that takes a hard turn towards "something must be there" even if not being used for leveling. I think this is the part I hone in on:
  • Document each patient encounter with:
    • The reason for their encounter and relevant history
    • Physical exam findings and earlier diagnostic test results
    • An assessment, a clinical impression, or a diagnosis
    • The rationale for ordering diagnostic and other ancillary services
    • A plan for care
    • The date of service and legible identity of the observer
I suppose I'm a stickler for black and white, but I know there is a lot of gray in coding. I'm not fond of the color gray. :)
 
Again, every CMS change in coding requirements in 2021 came out of a desire to simplify and minimize documentation requirements, eliminate audits and get rid of the compliance cottage industry that had evolved to ensure that EMR's were documenting appropriate code levels using the 1991 and 1995 physical exam criteria and such. We are no longer checking these boxes. Payors, including CMS, are not looking for documentation of physical exam, and the published CMS rules (MLN is a casual pamphlet and not considered canonical) support the physician or practitioner establishing what is medically appropriate to document.

I would ask it this way - I'm a practicing surgeon. In some cases, I will tell you that documenting a physical exam is medically unnecessary for my medical decision making. I started medical school in 2001 and have been building that medical expertise over more than 20 years. CMS and CPT policy both support my judgment as to what I document being adequate, as long as I document medical decision making. I agree that not documenting a physical exam (I'm ortho - it's an old joke that an ortho physical exam in the hospital is "looks good from the dooway") is poor form, but it is not the role of a coder to second guess my decision making.
 
This is one of those areas where CMS and the AMA part ways. Well, two areas. First, CPT editorial panel members frequently say that the CPT manual doesn't set documentation rules. But CMS wants a history and a physical exam, even though the code descriptors say otherwise. From CMS 100-04, chapter 12
For all E/M visits, history and physical exam must be performed in accordance with code descriptors, but history and exam no longer impact visit level selection. When practitioner time is used to select visit level, the full time must be completed; the general CPT rule regarding the midpoint for certain timed services does not apply.
Click to expand...

But the descriptors say the service includes a history and/or examination.

99234 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making.
When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
Click to expand...

So yes, there's conflict, but CMS and private payers get the final say in what they'll pay for. Where things remain murky is how much history and exam is enough.
 
You are misinterpreting that sentence, I think, and CMS is not saying anything different than CPT here.
"For all E/M visits, history and physical exam must be performed in accordance with code descriptors, but history and exam no longer impact visit level selection."
This implies that the CPT code descriptors are the relevant authority, and those code descriptors say only medically appropriate history and/or exam needs to be documented. This is punting back to CPT, and CPT confirms that a documented exam is not necessary when medically appropriate.
 
The CPT manual gives providers a choice (because the AMA's intent is to reduce work), CMS does not.

E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service.
Click to expand...
 
Perhaps the safest bet is to encourage your providers to provide at least a rudimentary exam to keep them out of trouble, if we think there is a potential for this to be interpreted as a requirement.

Payors can deny what they want to deny, and we can appeal, BUT, let's all be honest: arguing that not examining the patient conforms to "medically appropriate" is really not a winning argument in the court of public opinion... :)
 
Yeah, I kind of agree on both sides of the coin. I guess I've always just interpreted that as "medically appropriate" being the extent of the exam. In other words, you don't have to do a certain number of body systems or checks to qualify as an exam being done, and the exam extent certainly wouldn't figure into whether a provider got, say, a 99213 or a 99215. Code level is now determined to be due to medical decision making. But, for whatever the patient is there for, the doctor can determine what a 'medically appropriate' (extent of) exam would be. Back on 93 and 95 guidelines, we'd have check boxes as to what systems were examined and what they found to figure into E/M leveling, and that check system has been eliminated in the code level selection process. But I had always interpreted that sentence as something still had to be there. I always think, the doctor probably at least laid eyes on the patient and could document something there...?

Again, I think it could be seen both ways and is kindof a shady area. As I've mentioned, I'm not fond of gray.

Thank you for weighing in and your feedback!
 
He who pays the piper has to call the tune. Or as a friend says, The AMA/CPT doesn't pay claims, Medicare does. (Meaning you have to follow Medicare or the payer even when it contradicts CPT.)
 
You must log in or register to reply here.
Top