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Auditing Using 1995 Guidelines

  1. #1
    Default Auditing Using 1995 Guidelines
    Exam Training Packages
    When auditing the Exam, based on 1995 guidelines, the requirment is that 8 or more organ systems be reviewed when MDM is at a high or moderate level. Can anyone help in defining the Single Organ Exam based on the 1995 guidelines? My question is, when auditing documentation that focuses on a single organ, what is considered comprehensive or is it a must that 8 or more organ systems be reviewed, based on the 95 guidelines? FYI - EMR templates are are based on 95 guidelines is the reason for auditing with 95.

  2. #2
    Location
    Kansas City, MO
    Posts
    431
    Default
    95 guidelines don't have a a way to get a comprehensive exam focusing on one system like 97 guidelines do.
    In order to get a comprehensive exam using 95, you have to examine atleast 8 systems (not body areas).

    (unless of course you are doing and extended exam of that one system, you'd still need to examine atleast 7 other systems)

    If you work for a specialist who commonly focuses on one system, you may want to consider switching to 97 guidelines. Hopefully this is an option within your EHR system.

    Family practice, internist, gen surg usually do better with 95

  3. #3
    Default Single Organ System
    Quote Originally Posted by tcrespo View Post
    When auditing the Exam, based on 1995 guidelines, the requirment is that 8 or more organ systems be reviewed when MDM is at a high or moderate level. Can anyone help in defining the Single Organ Exam based on the 1995 guidelines? My question is, when auditing documentation that focuses on a single organ, what is considered comprehensive or is it a must that 8 or more organ systems be reviewed, based on the 95 guidelines? FYI - EMR templates are are based on 95 guidelines is the reason for auditing with 95.
    Hello,

    The examination is the largest difference between the two sets of guidelines. After reviewing a little of CMS 1995 DG, to address your question for a single orgam system exam using 1995 DG: The single organ exam is for 1997DG. As for your EHR requirements, I would certainly question this limitation you expressed. This affects $$.

    Documentation Requirement 1995 body areas or organ systems

    PF: 1 body area or organ system
    EPF: 2-4 body areas or organ systems, some carriers will alow 2-7 body areas or organ systems
    Detailed: 5-7 body areas or organ systems, some carriers will alow 2-7 body areas or organ systems
    Comprehensive: 8 or more organ systems; 8 organ systems must be examined. If body areas are examined and counted, they must number more than 8 organ systems

    Documentation Requirement 1997DG
    Multi-system guidelines:documenation of elements are identified by bullets
    Single Organ System: 1-5 elements identified by a bullet

    For comprehensive (your question) the extent of examinations is dependent upon clinical judgment and the nature of the presenting problem(s). Look for documentation supporting abnormal and relative negative findings of the affected symptomatic organ system, which should have been documented. Remember, a notation of "abnormal" without elaboration is insufficient. Abnormal or unexpected findings of unaffected organ(s) should be described. A brief statement including the words "negative" or "normal" is sifficient when describing normal findings to the unaffected areas.

    I have found providers to sometimes over document the exam because they think they must document everything. I have found that sometimes only one test or test review is sufficient for a complete organ system exam. Talk with the provider about how many tests needed, etc. to quantify the documentation. I really believe that is why we have the 1997DG . Those guidelines remove the element of uncertainty by stating you need two elements from 9 systems to qualify for a comprehensive exam. Under 1995, you only have the description of body areas and organ systems. These are listed in the CPT book.

    I hope this helps some, it is difficult sometimes to type all this stuff!
    KL
    CCS, RHIT, CPC, CMBS

  4. #4
    Default
    Thank you for the information. This is very helpful and just a reitteration of what I have been communicating. Greatly appreciate!

  5. #5
    Location
    Jacksonville, FL River City Chapter
    Posts
    74
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    Comprehensive -- a general multi-system examination or complete examination of a
    single organ system.

    See the direct quote above from the '95 Guidelines. They do have a way to get a comprehensive level exam focusing on a single system. They just don't define what a "complete" exam of the system is, requiring you to use your judgement the same as you do in the lower levels when deciding whether the level of exam detail should be described as a "limited" exam vs. an "extended" one.

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default Specialty Single System
    My recommendation is that you have the physicians in a given specialty outline what a comprehensive single system exam looks like. Let them make up their own bullet points.

    Put this information into your practice's Compliance protocol. When an auditor shows up you can demonstrate that you are holding everyone to the same standard for comprehensive.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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