# E/M ROS and Physical exam



## katrinnac (Jan 8, 2013)

I have a compliance company that audit my docs and i am having some issue i need some back up.

For a visit I am coding it as a 99202 as the exam portion brings the level down because they are only documenting Constitutional, head/face, eyes, ears, nose/mouth/throat and neck/thyroid. The Hx is detailed and they are saying the exam is detailed and MDM is moderate. They are coding this as a 99203.

Any thoughts on this? It was my understanding that we are not allowed to mix body areas with organ systems?! 

Also another problem i am having is they keep saying CMS wants 14 ROS for complete or a notation of 12,13 etc. are reviewed and all negative. can you provide any insite on this?

Thanks so much.

Katrinna Laude, CPC


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## kagal0816@verizon.net (Jan 8, 2013)

*Physical Exam & ROS*

Hi Katrinna - The first question that I have is which guidelines are you using '95 or 97's?  Is the external company utilizing the same set of guidelines?  The Company that is auditing the physician (based on my understanding of your post) was hired by your physician, and as such the external auditor should be able to provide a rationale.  Any time that I have dealt with external auditors and there was a disagreement, we have always had a discussion regarding the difference.  
Without more specific information regarding the exam performed, or without seeing the note any input would be a guess.  Hope that helps somewhat.  

Good Luck, Karen


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## rthames052006 (Jan 8, 2013)

katrinnac said:


> I have a compliance company that audit my docs and i am having some issue i need some back up.
> 
> For a visit I am coding it as a 99202 as the exam portion brings the level down because they are only documenting Constitutional, head/face, eyes, ears, nose/mouth/throat and neck/thyroid. The Hx is detailed and they are saying the exam is detailed and MDM is moderate. They are coding this as a 99203.
> 
> ...



You can check both sets of DG 95 and 97 for the specifics of the zrOS 
. I'd also tell you to check with your MAC because they may have some info as well. 

As fir the other issue with disagreeing with the external auditor, as another poster stated you should be able to get the companies rationale for 99203 vs 99202. 

Good luck.


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## katrinnac (Jan 9, 2013)

Karen- i use 95. thank you for your response here is the physical exam:
*Vital Signs*Time	BP mm/Hg	Pulse/min	Resp/min	Temp F	Height Ft	Height in	Wt lb	BMI kg/m2	BSA m2
10:14 AM	133/77	86		97.7	6.0	3.00	314.00	39.24	
Pulse Ox Rest	 Pulse Ox Amb	Pulse Ox	Liter per min





*Physical Exam
Constitutional:*No acute distress. Nourishment type is obese.  Well developed. 
*Head/Face:*
Facial features are symmetric. 
The skull is atraumatic (normocephalic). 
*Eyes:*
Right  
General eye condition is normal.
Lid/lash: normal.
No icterus.
PERRLA.
EOM's intact - no nystagmus.
Left 	 
General eye condition is normal.
Lid/lash: normal.
No icterus.
PERRLA.
EOM's intact - no nystagmus.
*Ears:*
Right 
Unremarkable to inspection. Pinna normal to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Normal tympanic membrane. 
Left 
Unremarkable to inspection. Pinna normal to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Normal tympanic membrane. 
Comments:
No evidence of ear abnormality on exam today.
*Nose / Mouth / Throat:*
External Nose: is unremarkable.
Right Nares:  No discharge.
Left Nares:  No discharge.
Nasal Mucosa:  No mucosal abnormality.
Septum: No septal deviation or perforation.
Right Turbinate: No right turbinate hypertrophy.
Left Turbinate: No left turbinate hypertrophy.
Lips/Teeth/Gums: Normal teeth and gums.
Tongue:  diffuse hypertrophy..
Buccal Mucosa: Normal buccal mucosa.
Salivary Glands: are normal.
Palate & Uvula: appear symmetric and normal.
Oropharynx:  No pharyngeal erythema or exudates or mucosal lesion.
*Neck / Thyroid: * 
Inspection reveals thick.  Palpation reveals trachea appears midline and mobile.  Parotid gland reveals hypertrophy.  No thyromegaly or thyroid nodules detected.  Range of motion is supple (normal).  No cervical adenopathy. 
Comments:
Diffuse bilateral parotid gland hypertrophy noted.  I was not able to palpate a discrete mass of the right parotid gland but secondary to neck fullness, I cannot be certain that this is not present.


Yes i am checking with the external auditor on how they got it. In the exam portion i was always taught that you can not mix body areas and organ systems in 95 but in 97 you can?! any thoughts on this? 

Thank you so much.

Katrinna Laude, CPC


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## kagal0816@verizon.net (Jan 9, 2013)

*E&M*

Hi Katrinna - To audit I use a form from Medical Templates.com.  
Here is a great reference: 
http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

Using 1995 guidelines, I can see how there is confusion.  Based on the information that I have from the note, my opinion would be split, it could go either way.  For instance, if your doctor is an ENT, I would lean more toward 99203, but if the doctor is an Endocrinologist, I would lean toward 99202.  This opinion is based on the whether it is an EPF or Detailed visit based on the provider's specialization  1995 DG's are wishy-washy.  When there is a dispute regarding levels, one question that I ask the provider is "If one of your peers reviewed this, do you think that they would agree?, which often "snaps" them back to reality.  Remember (and remind auditors) medical necessity is the over-arching criteria when choosing a level of service.  

I never combine body areas and organ systems - - never ever.  I believe that it is inappropriate in both sets of guidelines, but cannot say definitively.

This information of course does not take into account the CC, HPI, ROS (10 systems minimum) or MDM nor the insurance carrier's payment policies.

I would be interested to know the final outcome.  Karen


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## katrinnac (Jan 10, 2013)

thank you for your input. I will let you know the outcome.

Katrinna Laude, CPC


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## MikeEnos (Jan 15, 2013)

Assuming the History is Detailed and MDM is Moderate, I would absolutely agree that this is a level 3 new patient 99203.  

Using the 1995 guidelines, you can use multiple methods of calculating this as a Detailed exam.  You could use the CPT definition and describe this as an "*an extended examination of the affected body area(s) and other symptomatic or related organ system(s).*"  Or you could go by your local carrier's guidelines if they are more specific.  In my area, 2-4 body areas or organ systems is Expanded Problem Focused, while 5-7 is Detailed.   

Our carrier allows us to count documentation of body areas and organ systems up to the level of a detailed exam (on other words, we CAN mix and match for a EPF or Detailed exam.)  However, for a Comprehensive exam we must have 8 organ systems - body areas don't count.

Even if you're not sure if your carrier allows this, you have 5 organ systems (1) Constitutional (2) Eyes (3) ENT (4) Musculoskeletal (5) Lymphatic  [not to mention possibly (6) Psych for stating they are in no acute distress, though I usually count that as Constitutional - it could certainly be debated if you had your back to the wall.]  That's not including the Body Area of Head.  Certainly enough for a Detailed exam in my book.


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## jackiemal (Dec 4, 2014)

So this question is for Mike-

If you are using the organ systems would you count Normocephalic/Atraumatic as musculoskeletal?


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## chasarmil (Dec 9, 2014)

I got a detailed exam when I reviewed this.  I don't mix organ systems, but that depends on what your MAC's rules are.  For the MAC in my area, the difference between expanded problem focused and detailed is the 4 by 4 method.   Which means, 4 items in 4 different body areas or organ systems will give you a detailed exam versus an expanded problem focused.


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