Using 95 Documentation Guidelines

eeoo

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I have always understood the 95 Exam Criteria to be:

Problem Focused Exam- One organ system or one body area
Expanded Problem Focused Exam- 2-4 Organ Systems
Detailed Exan- 5-7 Organ Systems
Comprehensive Exam- 8 or more Organ Systems

However, the number of organ systems above are not listed specifically in the 95 Exam Documentation Guidelines. Does anyone know where these are listed or clarified in order to defend an audit of a medical record? Also, can you count a body area the same as an organ system? Thanks!
 

tammylum

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Problem focused: Limited to affected (one) BA or OS identified in the chief complaint.

Expanded problem focused: Limited area of affected BA or OS + 2-7 BAs or OSs.

Detailed: Extended exam of affected BA or OS + 2-7 BAs or OSs.

Comprehensive: It encompasses a complete single speciality exam or complete multi-system exam.

The difference between expanded problem focused exam is limited and is focused on the BA/OS of the chief complaint and other directly related BA/OSs, whereas the detailed exam is extended and covers not only the BA/OS of the chief complaint, but other BA/OSs not related to chief complaint.

You can't count the same information twice as a BA and OS. It either goes under the BA or OS.

I just finished my class to become a certified coder and got this information from the 2008 workbook.

Tammy Lum
Upstate New York
 

cdcpc

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I have always understood the 95 Exam Criteria to be:

Problem Focused Exam- One organ system or one body area
Expanded Problem Focused Exam- 2-4 Organ Systems
Detailed Exan- 5-7 Organ Systems
Comprehensive Exam- 8 or more Organ Systems

However, the number of organ systems above are not listed specifically in the 95 Exam Documentation Guidelines. Does anyone know where these are listed or clarified in order to defend an audit of a medical record? Also, can you count a body area the same as an organ system? Thanks!

You are correct. The guidelines don't specifically say what number of organ systems equals what level of exam, but the amounts you stated above are an industry suggestion. (1 OS= problem focused, 2-4 =exp prob focused, 5-7 = detailed and 8 or more OS = comprehensive).
I have put these amounts on my audit form to show physicans and auditors exactly what standards I follow. A lot of other auditors out there follow these same suggestions. The important thing is that you make really clear what standards you follow and then stick with them.
You can count the number of body areas OR organ systems, but you cannot count one element as both a body area and organ system. For example, if the left leg was examined for a rash, I can count this as a body area OR as the skin organ system, but not as both. You can use it in the area that will help you most in the audit.

http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
 
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