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E&M exam description

  1. #1
    Question E&M exam description
    Medical Coding Books
    Can anyone tell me the difference between the desciption of the exam that states "AFFECTED body area/organ system and other symtomatic or related organ systems and EXTENDED exam of affected body areas/organs systems and other symtomatic or related organ systems"?
    I use the 1995 guidelines and both give 2-7 body areas or organ systems but one ends up being expanded problem focused and the other detailed.
    I use a free medical doc tool by MedicalTemplates that I found when doing a google search of auditing tools. If anyone has another auditing tool for the 1995 guidelines I would be interested in looking at that one too. I took an E&M coding course over 10 years ago and am now questioning everything I thought I knew lol
    Thanks!
    Jennifer

  2. #2
    Default
    Hi Jennifer,

    One way to move from EPF to Detailed in the physical exam is called the 4x4 method.

    Below is some information about the 4x4 method. Good Luck!

    What is the 4 x 4 method for determining if an examination is scored as an expanded problem focused or
    detailed?


    Under the 1995 guidelines both the expanded problem focused examination and the detailed examination provide for the
    examination of up to 7 systems or 7 body areas. This has led to variability in reviews utilizing the 95 guidelines, and
    requiring an interpretation for proper and consistent implementation of the E/M guidelines. By providing a tool we call 4X4
    (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be
    a detailed exam based on the reviewers clinical judgment) our reviewers and the physicians in PA have a clinically derived
    tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity. This tool is consistent with the way
    medicine is practiced, as confirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to
    Physical Examination by Barbara Bates, M.D. And, it is a tool to reduce reviewer variability.
    Highmark Medicare Services nurse reviewers follow the guidelines for auditing E/M services that are provided by CMS and
    the American Medical Association (AMA). This includes consideration of both the 1995 and 1997 guidelines, with the
    utilization of the guidelines that are most beneficial to the physician. We also instruct our nurse reviewers to use their
    clinical knowledge while reviewing the medical record documentation to determine the correct and appropriate level of care.
    Clinical inference overrides the 4 x 4 tool. It provides for an individual consideration, and makes the review of all services
    (including E/M examinations) fairer to the physician. Clinical inference is in keeping with CMS current instructions for
    reviewing all medical records. Again, our reviewers utilize either the 95 or the 97 guidelines when reviewing E/M services,
    and utilize the guidelines that benefit the provider.
    With all of this said, our reviewers utilize one of the following when making a determination on whether an examination is
    expanded problem focused or detailed. The method chosen must be the one that is most beneficial to the physician.

    1997 E&M examination guidelines,
    1995 E&M examination guidelines utilizing the 4 x 4 tool, or
    1995 E&M examination guidelines utilizing clinical inference.
    Martinni

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