# 1995 guidelines for exam question???



## mb12345 (Jun 8, 2009)

Hi Everyone,

Hope you all can help.  We are trying to find out what specifically is considered a " *Complete *Single Organ System Exam" based on the 95 guidelines.  

Per our intermediary "Trailblazer" it is undefined and we have doc's intent on using the 95 guidelines over the 97".  I cannot locate any specific language that tells me how to use the 95 guidelines for complete single organ system exam when auditing?  For examples: number of bullets...

Any takers?

Thanks
MaryBeth


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## Karolina (Jun 8, 2009)

So far as I am aware, there are no specific "bulleted" guidelines for the exam when using the 1995 guidelines. (This lack of specificity is one of the main reasons the 1997 guidelines were created.)
My audit tool (which is from NHIC) has a list of body areas/organ systems to choose from but doesn't provide much detail.
From what I hear, many auditors use the 1997 guidelines as reference. This is mostly to find the line between Expanded Problem Focused and Detailed exams.
Hope this helps a little bit, even if it's not exactly what you're looking for.


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## mb12345 (Jun 9, 2009)

Thanks, I had a feeling thre were no specifics!


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## LLovett (Jun 9, 2009)

95 doesn't allow for a complete (compehensive) single system exam. That is one of the big differences between 95 and 97.

Laura, CPC


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## amjordan (Jun 9, 2009)

This topic came up last year at a local chapter meeting.  There was one member that said her office had contacted their specialty society and a director at a medical school with the question of what they considered a comprehensive single organ system exam. (I don't remember which organ system) The information they received added up to a 28 point exam.  In turn, they took that information and educated all of their providers and then developed a coding and documentation policy to provide an outline for their comprehensive single organ system exam.  She then went on to explain that when their charts are audited, a copy of the policy is provided to the auditor.

Yes, it is allowed the problem is that there was no consensus as to what each single organ system exam should include, hence the 97 Guidelines.  Here is what the 95 Guidelines say:

The levels of E/M services are based on four types of examination that are defined as follows:
• Problem Focused -- a limited examination of the affected body area or organ system.
• Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
• Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
• Comprehensive -- a general multi-system examination or complete examination of a single organ system.​
The extent of examinations performed and documented is dependent upon clinical judgement and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.
_!DG:_ Specific abnormal and relevant negative findings of the examination of the
affected or symptomatic body area(s) or organ system(s) should be
documented. A notation of "abnormal" without elaboration is insufficient.
_!DG:_ Abnormal or unexpected findings of the examination of the unaffected or
asymptomatic body area(s) or organ system(s) should be described.
_!DG:_ A brief statement or notation indicating "negative" or "normal" is sufficient
to document normal findings related to unaffected area(s) or asymptomatic
organ system(s).
_!DG:_ The medical record for a general multi-system examination should include
findings about 8 or more of the 12 organ systems.​http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf


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## Karolina (Jun 9, 2009)

*Reg. Angela's note*

Basically this refers back to the principle if there is no detailed guideline, write and implement a policy and stick to it. 
This makes sense.


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