EM Coding Alert

Question: Our office is located in New Jersey, and we see patients from Pennsylvania, too. Concerning last month’s article about the NGS ruling around the physical exam, can you tell me more about the rules concerning expanded problem focused and detailed exams from MACs in the states where we see our patients?

New Jersey Subscriber

Answer: The Medicare administrative contractor (MAC) Novitas Solutions, Inc. covers New Jersey and Pennsylvania for Jurisdiction L, as well as Delaware, Maryland, and Washington, D.C.

Novitas Solutions adheres to a policy called the 4x4 method to determine if a physical exam is expanded problem focused or detailed.

Per the Novitas method, providers who see patients would examine and, thus, document their exam to include at least four organ systems and detail at minimum, four pieces of information around each of those systems, says Suzan Hauptman, CPC, CEMC, CEDC, AAPC Fellow, senior principal at ACE Med Group, Pittsburgh, Pa. Fulfilling these requirements qualifies as a detailed exam.

However, unlike the NGS rule we discussed in our last issue, Novitas does provide a caveat that if you don’t meet the 4x4 rule, the review nurses could still consider a detailed exam of less than four systems — when details are present in the other systems, says Hauptman.

The Novitas policy adds that nurse reviewers should follow CMS and American Medical Association (AMA) guidelines for auditing E/M services. Reviewers can consider both the 1995 and 1997 guidelines and choose the guidelines that are most beneficial to the physician.

Nurse reviewers should apply their clinical knowledge when looking at the medical documentation and determining the correct level of care, emphasizes the policy.

“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,” adds the policy. “Clinical inference is in keeping with the CMS current instructions for reviewing all medical records.”

Also, according to the policy, Novitas reviewers should utilize one of the following when choosing whether an exam is expanded problem focused or detailed:

• 1997 E/M examination guidelines
• 1995 E/M examination guidelines utilizing the 4 x 4 tool
• 1995 E/M examination guidelines utilizing clinical inference.