# 4x4 method



## RADCODER

Does anyone understand the verbiage.. "Clinical inference overrides 4 X 4 tool" given by Novitas Solutions in their E/M auditing webinar? It is also  referenced  in a FAQ...



10.  What is the 4 x 4 method for determining if an examination is scored as an expanded problem focused or detailed?

Under the 1995 guidelines both the expanded problem focused examination and the detailed examination provide for the examination of up to 7 systems or 7 body areas. This has led to variability in reviews utilizing the 95 guidelines, and requiring an interpretation for proper and consistent implementation of the evaluation and management (E/M) guidelines. By providing a tool we call 4X4 (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment) our reviewers and physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity. This tool is consistent with the way medicine is practiced, as confirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to Physical Examination by Barbara Bates, M.D. And, it is a tool to reduce reviewer variability.
Novitas Solutions nurse reviewers follow the guidelines for auditing E/M services that are provided by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA). This includes consideration of both the 1995 and 1997 guidelines, with the utilization of the guidelines that are most beneficial to the physician. We also instruct our nurse reviewers to use their clinical knowledge while reviewing the medical record documentation to determine the correct and appropriate level of care. Clinical inference overrides the 4 x 4 tool. It provides for an individual consideration, and makes the review of all services (including E/M examinations) fairer to the physician. Clinical inference is in keeping with the CMS current instructions for reviewing all medical records. Again, our reviewers utilize either the 95 or the 97 guidelines when reviewing E/M services, and utilize the guidelines that benefit the provider.
With all of this said, our reviewers utilize one of the following when making a determination on whether an examination is expanded problem focused or detailed. The method chosen must be the one that is most beneficial to the physician.
?	1997 E&M examination guidelines,
?	1995 E&M examination guidelines utilizing the 4 x 4 tool, or
?	1995 E&M examination guidelines utilizing clinical inference.
Date Posted: 10/05/2009, Date Revised: 11/15/2013


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## thelton

That means if the 4x4 (4 things documented in 4 organ systems or 4 body areas) isn't met, an auditor can still determine that an exam is detailed rather than expanded problem focused.  Novitas also does not allow you to mix body areas and organ systems....it has to be one or the other.


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## RADCODER

That's what we thought, but why would the provider still be entitled to a "Detailed" exam without meeting all elements? Or how does the auditor make that judgement call? Simply because they can?


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## MarcusM

Clinical inference is part of the clinical decision-making process and precedes judgment and action. It is an integrated response to patient cues and other evidence and a necessary skill with reasoning strategies that are a key component in many medical tasks, including decision making, clinical problem solving, and understanding of medical texts. Identification of reasoning strategies used by clinicians may prove critical in comprehension of clinical information with the types of reasoning and strategies varying among clinicians; especially as a function of expertise, knowledge, and problem difficulty. 

As an example, I used to manage a cardio clinic. We had a patient walk in without an appointment. The desk person told him he would have to wait for quite awhile. I overheard this, looked at the elderly gentleman and asked him if he had run across the parking lot? He said, nope, just woke up this morning like this..."This" was SOB, almost panting, with blueish lips...I leaned out the window and told him to sit in the wheelchair, got a nurse to go evaluate, & she was skeptical of my concerns that he was "a walking heart attack."  She did an EKG, turned pale, skipped to the doctor's exam room and grabbed the cardiologist to show him the EKG strip. He turned pale and instructed her to wheel the patient across the street to the hospital ER and he would meet her there in a few minutes. He called the ER and told them to set up an emergency STAT OR to do surgery. The doctor and the patient later thanked me for recognizing the severity of this case.


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