# E/M question about 1995 guidelines



## HCCCoder (Aug 26, 2008)

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


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## kamikidd (Aug 26, 2008)

*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


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## aguelfi (Aug 27, 2008)

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


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## HCCCoder (Aug 27, 2008)

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


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## dmaec (Aug 27, 2008)

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}_


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## ARCPC9491 (Aug 27, 2008)

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/Rework_Sep06/PDF files/Part 3 Doc an Exam w RevQuiz.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.


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## Lisa Bledsoe (Aug 27, 2008)

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


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## HCCCoder (Aug 27, 2008)

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


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## ticooper (Aug 27, 2008)

*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.


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## dmaec (Aug 27, 2008)

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....


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## HCCCoder (Aug 27, 2008)

This is what I just read about the line;
"Use of a checklist or template is acceptable. If a checklist is used to document the examination, written descriptions with positive or negative findings should be documented for any area or system related to the problem or complaint. Using a line drawn down a checklist is not sufficient unless the documentation very clearly defines the exact system and area examined. Most coders and auditors will advise physicians and physician extenders not to use lines but to define the area or system examined more clearly by using a check mark or circle".


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## dmaec (Aug 27, 2008)

lmartirosyan-
yup... I'd agree with that completely.  It's neither right or wrong, it's advised against, and it's not liked by coders or auditors... but in the end, after it's all said and done - it can be done that way. (line-through) documentation supporting of course.


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