# Counting elements in the exam.



## buppkl (Mar 13, 2019)

We seem to be having a huge debate in the office on the way we coders score our E/M services. Maybe we are looking into this too deep but it sometimes depends between a 99213 vs 99214.
When a provider states something like Pulses: normal in all four extremities, would you count that as 1 element in the cardiovascular exam or as some believe, it is 4 different pulses so count it as 4 elements?
Same issue when provider states Respiratory: lungs clear bilaterally to A&P, is that 2 elements or 4 for both right and left lung?
Also, can you pull elements from anywhere in the exam to use in specific systems as long as not using that element twice? ex: provider lists extremities, no clubbing, cyanosis, deformity or edema. Can you take the clubbing, cyanosis and edema and use it with the 1 element that was under pulses as the 4 elements in Cardiovascular? The provider in this case already listed 4 elements under musculoskeletal so can what he states in "extremities" be used in cardio? The providers are always mixing systems and areas but we count in one or the other, never twice.
We all have different views on what to count when scoring. Any help appreciated.


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## thomas7331 (Mar 13, 2019)

If you are using the 1995 guidelines and counting organ systems or body area, you can only count each organ system or body area once regardless of how many findings are documented.  So in your example, pulses, clubbing, cyanosis, etc., being findings related to the cardiovascular system, would only allow you to count that one system and all of the respiratory findings would also just count as a single system.  However, if counting body areas instead, pulses in both lower extremities could be counted as two extremities, plus the exam of the chest (heart and/or lungs) would be a third body area.  There are no 'points' or 'elements' under 1995 guidelines - you just count the number of either systems or body areas (but not both).

1997 guidelines, on the other hand, are much different, and you count the 'bullet points' for the type of exam that was performed.  If you look at those guidelines, you have a point-by-point list of the findings that must be documented, and under each exam, it will tell you how many of those points are required for each level of exam, e.g. detailed, comprehensive.  

And yes, you pull from anywhere in the exam - you look at the finding, not at the category where the provider has chosen to document it.  

Hope this helps some.


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## buppkl (Mar 13, 2019)

Thanks for your reply. Not sure where you are located and who your MAC provider is but Novitas is our MAC provider and they have developed the 4x4 rule to determine when the exam meets a detailed exam. So to count 4 systems and 4 elements in each, our debate is whether for the cardio system would you consider pulses in all 4 extremities as 4 elements, or just pulses as 1 element in the system. Clubbing, cyanosis and edema would be the other 3 if only using pulses as 1. And for the "lungs clear bilaterally to A&P" statement, would you count 2 or 4 (2 x each side)?


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## thomas7331 (Mar 13, 2019)

buppkl said:


> Thanks for your reply. Not sure where you are located and who your MAC provider is but Novitas is our MAC provider and they have developed the 4x4 rule to determine when the exam meets a detailed exam. So to count 4 systems and 4 elements in each, our debate is whether for the cardio system would you consider pulses in all 4 extremities as 4 elements, or just pulses as 1 element in the system. Clubbing, cyanosis and edema would be the other 3 if only using pulses as 1. And for the "lungs clear bilaterally to A&P" statement, would you count 2 or 4 (2 x each side)?



Ah, OK, I have never worked under this MAC or with any that use the 4X4 rule so have no first-hand experience with how they audit.  You may want to query Novitas about this as I've heard they are fairly responsive but I don't know if that is actually the case.  Another thing I've found very useful is to appeal any cases where the payer has requested documentation and down-coded a service.  Even if you agree that the down-coding was correct, by appealing you can get a more descriptive explanation that may give you insight into how the auditors do their work.  I'd just say though, that from my own experience with the MACs, they are really a lot less concerned about how you count the history and exam than they are about the level of service being appropriate for the nature of the presenting problem.  Medicare's proposed revisions to the E&M documentation requirements also suggest this is how they are beginning to see things.  

Just taking a quick look at Novitas' web page about the 4X4 rule (link below) it looks like they allow some flexibility in how you count your exam:  "_When reviewing a medical record and scoring the exam, our medical staff will automatically score a detailed exam if 4 or more exam items are noted in the medical record for 4 or more body areas or organ systems. *However, less than such can still be a detailed exam based on the reviewer's clinical judgment*, which is considered clinical inference_. "  I guess, like any guidelines, they are just that - meant to guide you and not to be a hard and fast rule, so you may just have to make a common sense decision internally as to how you want to manage this.  E&M is never black and white!

https://www.novitas-solutions.com/w...howHeader=false&_adf.ctrl-state=9a3l006w0_120


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## meghanhannus (Mar 13, 2019)

buppkl said:


> We seem to be having a huge debate in the office on the way we coders score our E/M services. Maybe we are looking into this too deep but it sometimes depends between a 99213 vs 99214.
> When a provider states something like Pulses: normal in all four extremities, would you count that as 1 element in the cardiovascular exam or as some believe, it is 4 different pulses so count it as 4 elements?
> Same issue when provider states Respiratory: lungs clear bilaterally to A&P, is that 2 elements or 4 for both right and left lung?
> Also, can you pull elements from anywhere in the exam to use in specific systems as long as not using that element twice? ex: provider lists extremities, no clubbing, cyanosis, deformity or edema. Can you take the clubbing, cyanosis and edema and use it with the 1 element that was under pulses as the 4 elements in Cardiovascular? The provider in this case already listed 4 elements under musculoskeletal so can what he states in "extremities" be used in cardio? The providers are always mixing systems and areas but we count in one or the other, never twice.
> We all have different views on what to count when scoring. Any help appreciated.



Hello,

I see Novitas updated the 4X4 method around the time the 1995 Exam guidelines changed for Expanded Problem Focused and Detailed Exam. As far as your question in regard to the cardiovascular/respiratory exam you would not count as 2 or 4 elements, it would only be one element for Cardiovascular Organ System and one for element for the Respiratory Organ System following the 1995 guidelines. If following the 1997 guidelines it would depend on the Specialty Exam and bullet points. You can check out E/M University for information on that: https://emuniversity.com/SpecialtyExams.html

For your second question if following the 1995 guidelines the extremities/no clubbing, cyanosis, deformity would be one element for the the Musculoskeletal Organ System and edema would be for one element for the Cardiovascular Organ System. So I have from the information you listed following the 1995 guidelines the following organ systems: Cardiovascular, Respiratory and Musculoskeletal. Again, for the 1997 Specialty Exams bullets will depend on the specialty so be sure to check out the link to E/M University I provided.


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