Forum - Questions & Answers

Apr 6th, 2016 - Sivakrishna

Detailed vs EPF examination

In the E/M documentation guidelines, what does 'more detail' regarding the exam mean, and what is the difference between an expanded problem-focused exam and detailed exam?

My providers are documenting general system and two points related to skin always. Can we consider them as detailed exam?

Apr 15th, 2016 - alincoln 2 

re: Detailed vs EPF examination

It's really a debatable element - nothing set in stone since the guidelines state 2-7 organ systems for both EPF and Detailed.
Some CMS MAC's define the difference for you - for example Palmetto defines a Detailed Exam using 1995 Guidelines as "2x2" - 2 elements for two different organ systems and they would consider that a Detailed Exam. NGS Medicare on the other hand stated in a FAQ that 6 organ systems are required for a Detailed Exam.

I know there is another carrier (can't remember which) that states Detailed is "2x4" - 2 elements for 4 different organ systems.

Palmetto:
FAQ/EM by Palmetto

"Question: In the E/M documentation guidelines, what does 'more detail' regarding the exam mean, and what is the difference between an expanded problem-focused exam and detailed exam?

Answer:
The 1995 body systems expanded problem-focused exam requires documentation of the affected body system plus one through six other body systems. The 1995 body areas expanded problem-focused exam requires documentation of the affected body area plus one through six other body areas.

The 1995 body systems detailed exam requires documentation of two through seven body systems with more detail. The 1995 body areas detailed exam requires documentation of two through seven body areas with more detail.

'More detail' refers to the extent of the exam. The level of detail involved in an exam is a clinical judgment based on the documentation for each individual medical record. There is an expectation that the exam will be more involved, and therefore more documentation would be submitted for a detailed exam. The documentation for a detailed exam would consist of at least two findings for at least two body areas or two organ systems.

Example:
Abdomen: soft, nontender, BSx4
Respiratory: Lung CTA, no wheezing or rhonchi"



NGS Medicare:
Assessing Your Evaluation & Management Services Documentation by NGS Medicare on Apr 26 2011.

"Q3. What exactly is required for an expanded problem focused exam using the 1995 E/M guidelines? Can I use body areas and/or organ systems? How many are needed?

A: According to the documentation guidelines, an expanded problem focused exam is a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). At this level, using the ’95 Guidelines 2-5 body areas or organ systems must be documented. You may use either body areas or organ systems in all levels except the comprehensive. At the comprehensive level, only organ systems are accepted


Q4. What exactly is required in terms of the number of body areas and/or organ systems to qualify for a detailed exam using the 1995 E/M guidelines?

A: According to the documentation guidelines, a detailed exam is an extended examination of the affected body area(s) and other symptomatic or related organ system(s).At this level, using the ’95 Guidelines, 6-7 body areas or organ systems must be documented. You may use either body areas or organ systems in all levels except the comprehensive. At the comprehensive level, only organ systems are accepted."



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