Auditing the exam 1995 Guidelines

February 11th, 2009 - Codapedia Editor

Categories: Audits/Auditing Coding Evaluation & Management (E/M)

Auditors breathed a huge sigh of relief when the 1997 Guidelines were released. The exam component was specific, clear and defensible in all four areas: problem focused, expanded problem focused, detailed and comprehensive. There were even specific instructions for single specialy exam elements. Auditors celebrated.

Physicians of some specialties, did too. The single specialty exams for Psych, eye, ENT and some others fit the bill. For many physicians, however, using the 1997 single specialty exam meant adding in more detail than they did before, and thus increased time and resources.

Any clinician is still allowed to use whichever set of Documentation Guidelines are more beneficial to them as the clinician, and payers are required to use either set, as well.

This article is about the 1995 exam. We know that exam is only one component of an E/M service. Review the other articles about auditing in Codapedia. The articles are broken up by topic, but all work together.

The 1995 exam, like the 1997 exam, has four levels: problem focused, expanded problem focused, detailed and comprehensive. Here is how they are defined exactly from the 1995 Documentation Guidelines: (Highlights, italics are mine)

B. DOCUMENTATION OF EXAMINATION
The levels of E/M services are based on four types of examination that are defined as follows:
• Problem Focused -- a limited examination of the affected body area or organ system.
• Expanded Problem Focused -- a limited examination of the affected body area or organ
system and other symptomatic or related organ system(s).
• Detailed -- an extended examination of the affected body area(s) and other symptomatic
or related organ system(s).
• Comprehensive -- a general multi-system examination or complete examination of a
single organ system.

!DG: The medical record for a general multi-system examination should include
findings about 8 or more of the 12 organ systems.

For purposes of examination, the following body areas are recognized:
• Head, including the face
• Neck
• Chest, including breasts and axillae
• Abdomen
• Genitalia, groin, buttocks
• Back, including spine
• Each extremity

For purposes of examination, the following organ systems are recognized:
• Constitutional (e.g., vital signs, general appearance)
• Eyes
• Ears, nose, mouth and throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic/lymphatic/immunologic

A problem focused exam is easy: it is a limited exam of the affected body area or organ system. One exam element from either the list of body areas or organ systems.

A multi-system comprehensive exam is easy, too: it is an exam of 8 or more organ systems (not body areas.)

The difficulty is in differentiating between an expanded problem focused exam and a detailed exam. First, no numbers of elements are listed in the Guidelines. Both an expanded problem focused exam and a detailed exam are 2-7 body parts/organ systems by a strict reading of the Guidelines. An expanded problem focused exam is a limited exam of the affected body area or organ
system and other symptomatic or related organ system(s) and a detailed exam is an extended exam of the affected body area or organ system and other symptomatic or related organ systems(s).

What is the difference between the two? The difference between a limited and an extended exam. What is the difference between a limited and an extended exam? Not defined by the Documentation Guidelines. How do you audit in that case?

My colleague and friend, Barb Pierce, won't use the 1995 guidelines to differentiate between an expanded problem focused and detailed exam. At her terrific auditing workshops, she says that it's just to gray to defend in an audit, and if she can't make a comprehensive, eight organ system exam, but it's more than a problem focused exam, she switches to the 1997 Guidelines. This is a reasonable, conservative approach.

Some groups and some payers use 2-4 body areas and/or organ systems for the EPF and 5-7 body areas and/or organ systems. If you elect to do this, make sure your own carrier uses this distinction. This distinction leaves very little difference in the exam, and makes if very easy to get a detailed exam.

Some auditors try to define the difference between a limited and extended exam, and write that down as a policy for their auditors to follow.

The difference between these two levels often makes the difference in the code selected. If there is too much variability or subjectivity in the auditing, the audit becomes less reliable. Do you audit the exam the same way every time? Do all auditors in your department do that? Using Barb Pierce's method will certainly increase the reliability of your audits, when the exam is between EPF and Detailed.

The multi-specialty 1995 exam is easy: 8 organ systems examined, in whatever detail the clinician finds clinically relevant.

The single specialty 1995 exam is defined as: "a complete examination of a single organ system." There's no help in the Guidelines as to what makes up a complete examination of a single organ system. Some groups set their own guidelines before the 1997 Guidelines were released. However, now that CMS and the AMA have agreed on a single specialty exams, I would be very cautious about a home grown policy. If you are using a single specialty exam, use the 1997 ones, which are explicit and clear.

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