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1995 Guidelines for Exam

  1. Default 1995 Guidelines for Exam
    Medical Coding Books
    When using 1995 Guidelines for Exams, I have found some coders were trained to use different criteria:

    Some coders were trained to use:
    2 through 4 body systems/areas to identify a Expanded Problem Focused exam, and 5 through 7 body systems/areas to identify a Detailed exam.

    Other coders were trained to use:
    2 through 7 body systems/areas (without a system detailed) to identify a Expanded Problem Focused exam, and 2 through 7 body systems/areas (with one system detailed) to identify a Detail level of exam.

    Is it appropriate to use either of the above criteria for distinguishing the level of exam? Is one more appropriate over the other for government programs such as Medicare?

    Thank you
    Last edited by Julie Zunker; 06-16-2010 at 09:59 AM.

  2. #2
    Portland, Maine
    I have the same question! CPT and Medicare guidelines are so vague. They state that a detailed exam is: Extended examination of the affected body area(s) and other symptomatic or related organ system(s).
    Does that mean that one OS or BA should be in detail and other affected ones don't have to be examined and documented in detail?
    Because these definitions are so vague, I think you have to develop internal policies as what exactly you will call a detailed exam.
    When I was studying for CEMC exam, I understood from AAPC slides that two or more BA or OS should be documented in detail, then I have another coder tell me that the word "extended" applies only to the affected OS or BA.

    I would like more replies from other coders!

    Santa, CPC, CEMC

  3. #3
    Daytona Beach, FL
    I agree that they are very vague and I have also seen where if you have 2-4 it is expanded and 5-7 is detailed. Highmark, our Medicare carrier, teaches us that they use a criteria they refer to as 4 x 4 for when they audit charts. They state if the doctor reviews at least 4 systems with 4 statements given in each system, they consider that a detailed exam. They also state that this is just a guideline and they will use their discretion for other circumstances - such as documentation of 7 areas with detailed documentation in some of these areas. The only clear thing I get out of this is the the 4 of 4 - otherwise they are still not giving a concrete answer to the question!

    When I review my docs charts, I usually see how many areas they examined and how detailed they were in those areas. If they only reviewed 2-7 areas without any detail (say one thing in each system), I give it expanded problem focused. If they review say 4-7 areas with a description and some detail in at least three or four systems, I give it Detailed. It really depends on how much the doctor is saying about each system.

    Although I like the 95 guidelines and find it easier to follow then trying to count bullets (that always confuses me), it is very vague! Maybe someday they will create a better system with less confusion!
    Jodi Dibble, CPC

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