Wiki Question on Physician documentation requirements for EXAM


True Blue
The Woodlands, TX
Best answers
We use the 95' guidelines for our E&M coding and auditing. One of my physicians will document both body areas and organ systems under her Exam portion. It was my understanding that the coder is not suppose to combine those or count both to get the 8 required for a comprehensive level; it should be one or the other. My physician disagrees and does not find documentation stating it must be either body areas or organ systems documented.

This is what she said: Why would I have to say “respiratory” if chest is said and the clinical findings described could only be attributed to the respiratory system. We looked it up and Medicare does not require exact verbiage, just that the system/body area is described. Medicare requires one comment on each Organ system. If I say, chest is clear to auscultation with no weezes or rales, that can ONLY apply to the respiratory system.

Am I wrong? If not, is there documentation by CMS stating otherwise that I can give to her?

Thanks for any input/suggestions.
Here's the DG from the 1995 Guidelines:

The levels of E/M services are based on four types of examination that are defined as follows:

Problem Focused -- a limited examination of the affected body area or organ system.

Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Comprehensive -- a general multi-system examination or complete examination of a single organ system.

My interpretation of these guidelines is that for PF, EPF and D; you may count either BA or OS. Comprehensive exams count OS only. Further, the E&M Coding Worksheet (July 2010) published by our local carrier, NHIC, specifically shows the following:

PF: 1 (BA) or (OS)

EPF: Limited exam of affected BA or OS)
2-4 (OS) and/or (BA)

Det: (Extended exam of affected BA or OS and other symptomatic or related OS(s)

5-7 (OS) and/or (BA)

Comp: Extended exam of affected BA(s) and other or related OS(s)
8 or more (OS) (A general multisystem exam or complete exam of a single organ system)

As you can see, NHIC indicates either BA or OS. Not sure if your carrier is so specific. So we count both OS and BA for the 95 exam, except for Comprehensive, where we count only Organ Systems. Hope this helps. Pam
According to our local carrier, Novitas, you either use body areas or organ systems and cannot combine the two. However, it is what is examined that is what counts, not what the "heading" is on the note.

For example - if the note states Head, which is a body area, you would get credit for the head under body areas if the doctor only states normocephalic, but if under head they state eyes reactive to light, oral mucosa pink - you can get credit for both eyes and ENT under the organ systems. In your question - if the note states Chest and the doctor says assymetrical, then that would be under body area, but if they say clear to ausculation then that is organ system - respiratory. Other examples - Neck - supple (body area) no adenopathy (organ system - lymph); Extremities - no deformity, no edema (body area or organ system - musculoskeletal or cardio for the edema).

Basically it depends on what the doctor is commenting on as to whether you can count it as an organ system or body area (or sometimes towards both). Of course you may want to check with your medicare carrier as they all seem to look at it differently.

Hope this helps!
I agree with Jodi-our local carrier is Novitas as well adn per a question on their website:

4.Under the Examination Section of the 1995 Scoresheet, can we combine the body areas and organ systems?

No. The examination section of the 1995 score sheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record you can use either the body areas or the organ systems. There is a dotted line between the body areas and organ systems indicating you must choose one or the other. If you combined the body areas and organ systems you would be giving credit twice which would be incorrect when determining the final score for the examination section of the score sheet. An example could be: the documentation in the patient's medical record stated, abdomen soft, credit can only be given in the body areas under abdomen or in the organ systems under Gastro Intestinal (GI) which ever area benefited the physician the most.

hope this helps
And since you have to use one or the other it should be organ systems since there are only 7 body areas and it takes 8 to qualify for a complete/comprehensive exam. Also, just to add E/M university states for the 95 guidelines that "you can't use body areas to complete the comprehensive exam".
Body areas vs Organ systems

Below is for the 1995 guidelines ...

If you are counting body areas EACH extremity counts as it's own body area.
So if you examine both arms and both legs you have 4 body areas.

If you are counting ORGAN SYSTEMS - exam of the extremities may count as one or more of the following:
musculoskeletal (e.g. range of motion)
neuro (numbness or pain)
integumentary (rashes or bruising)
cardiovascular (pulses, edema)

It all depends on the documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC