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E/M question about 1995 guidelines

  1. #1
    Location
    Woodland Hills, CA
    Posts
    121
    Question E/M question about 1995 guidelines
    Medical Coding Books
    Hello all,
    I used to always go by 1997 guidelines. I changed my job and now they require us to use 1995 for general multi-system.
    I have this medical record, where I want to make sure I get the correct level of the physical exam.
    It is written:
    Area Normal
    GENERAL
    SKIN
    HEENT
    NECK
    BREAST
    CHEST
    HEART
    ABDOMEN
    EXTREMITIES
    GU/PELVIC
    NEURO

    There are 2 columns one says "Area" and other one "Normal" and doctor draw a line from top to the bottom, indicating that every system examined was normal.
    First of all, is it OK when doctor just draws a line from top to the bottom under column "normal"?
    And second, do you get comprehensive PE, according to 1995 guidelines?
    Do you get 8 bullets?

    Thank you in advance,
    Lilit
    Last edited by HCCCoder; 08-26-2008 at 03:14 PM.
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  2. #2
    Default 95 guidelines for comprehensive exam
    First, for a comprehensive exam, body areas do NOT count, only organ systems. While the 95 guidelines do not specifically state how many organ systems must be evaluated for a comprehensive exam, conventional wisdom states that it is eight (8).
    The organ systems are:
    • Constitutional (e.g., vital signs, general appearance)
    • Eyes
    • Ears, nose, mouth and throat
    • Cardiovascular
    • Respiratory
    • Gastrointestinal
    • Genitourinary
    • Musculoskeletal
    • Skin
    • Neurologic
    • Psychiatric
    • Hematologic/lymphatic/immunologic
    It does not appear that the doucmentation supports a comprehensive examination. Since there is no detailed exam of an affected area/organ system, this looks like it would be an expanded problem focused exam at most. Each organization should have a documented policy and procedure to include how the the levels of the 95 guidelines interpret each level and what is required in the documentation of the clinical records to achieve each level.

    Secondly, the documentation should reflect exactly what was examined and found to be normal. This is recommended not only for coding but also from a clinical quality perspective. Say the patient has complications from a heart mumur, we have no documentation to show if the heart mumur was present or that the heart was asculatated on this visit.

    Feel free to contact me if you have any further questions.

    Helen L. Avery, CPC, CHC
    Senior Consultant
    Helen.Avery@Sinaiko.com

  3. #3
    Default
    Actually body ares are recognized as well are organ systems. The guidelines are on the following CMS website and it does describe on page 10 what the guidelines are for documention abnormal findings and such.


    http://www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp
    adrianne, cpc

  4. #4
    Location
    Woodland Hills, CA
    Posts
    121
    Default
    Thank you all.
    I went to that CMS web site and this is how it states:
    "The medical records for a general multi-system exam should include findings about 8 or more of the 12 organ systems".
    Does this not mean, that I already have 6 organ systems (correct me if I am wrong). What happens to the body areas, can't we not count those?
    Do I have EPF or Detailed exam, based on 1995 guidelines?
    I am confused, please help .
    Thanks,
    Lilit
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  5. #5
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    lmartirosyan: by my count you have 8 organ systems and 2 body area's in this pre-established list-
    GENERAL would fall under constitutional (although it's only 1 of 3 needed) = 0 organ system
    SKIN -inteumentary - = 1 organ system
    HEENT- eyes, & ENT, Mouth - = 2 & 3 organ system
    NECK - = 1 body area
    BREAST - = 2 body area (chest,breast)
    CHEST - = 2 body area (chest,breast)
    HEART - cardiovasc - = 4 organ system
    ABDOMEN - gastrointestinal - = 5 organ system
    EXTREMITIES - musculoskeletal - = 6 organ system
    GU/PELVIC - genitourinary - = 7 organ system
    NEURO - neurologic - = 8 organ system

    That being said - if everything is normal, why'd the patient come in? What's wrong, whats being checked? or is this a routine physical exam? otherwise "something" has to be wrong... ya know??

    here's a nice site, explains it rather well - the guidelines and such - gives examples also. "lines through a list are fine, as long as the issue area's are elablorated on a bit more"
    http://coding.aap.org/content.aspx?aid=10419
    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  6. #6
    Default
    For ENMT - I've always been advised that a notation of "normal" wouldn't suffice for an exam of all ears, nose, mouth, throat - the physician isn't 'specifying' what exactly is normal and that we shouldn't assume all components of ENMT are normal and that these should documented seperately. Anyone else been taught that way?

    Here's a nice link:
    http://www.tulane.edu/~contract/Rewo...%20RevQuiz.pdf


    For a comprehensive exam, you can't use body areas as a determining factor, only 8 or more organ systems. If you do use body areas, it must be above and beyond the 8 organ systems.

  7. #7
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I tend to use 95 guidelines for the most part. You have the option of body areas or organ systems, you cannot mix and match. So if you are counting organ systems and a body area is also documented as part of the exam, it won't count. There are 12 organ systems and 7 body areas. Try this link for a sample audit tool and see if it is helpful. http://www.msbcbs.com/PDFFiles/emsr/EM_Worksheet.pdf
    Lisa Bledsoe, CPC, CPMA

  8. #8
    Location
    Woodland Hills, CA
    Posts
    121
    Default
    So, can anyone tell me the level of the PE for this case?
    Thanks Lisa and ARCPC, the link was very helpful.

    Thanks a lot,
    Lilit
    Last edited by HCCCoder; 08-27-2008 at 09:36 AM.
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  9. #9
    Default T cooper
    As an auditor I wouldn't accept the line from top to bottom on the exam. The physician needs to state findings. We can't really argue that he didn't check but that is too gray and will leave the physician open to quesions. If you question it then so will an outside auditor. Yes, in order to get a comprehensive exam you have to have 8 systems evaluated.

  10. #10
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    ticooper - I was actually going add that auditors don't like it, but - there really isn't anything that says they can't do it, as long as they document accordingly, normal or abnormal (and the findings if abnormal). It is a gray area - The longer I'm a coder, coding - the more it seems it's ALL gray

    I know several auditors have told us the same, they don't like - our providers do not use the "line through" method. (at my other place of employment they did). It's arguable, and they (providers) always won the argument.. with a suggestion from the auditors "not" to do it that way....
    Donna, CPC, CPC-H

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