Medicare Compliance & Reimbursement

Planned EPF and detailed exams updates are no longer considered mandatory.

In a surprising reversal from its earlier decision out this summer, the Medicare Administrative Contractor National Government Services (NGS) rescinded its policy change regarding evaluation and management (E/M) expectations for expanded problem-focused and detailed exams.

Update: NGS announced its planned change to expanded problem-focused and detailed exam requirements will no longer be considered mandatory for physicians.

"In my opinion, although the detailed exam representing six to seven body areas or organ systems is no longer mandatory, I suggest practices under NGS still follow this because it has less ambiguity than the alternative," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, Vice President at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. "On audit, the chart can easily be defended as documenting a detailed exam if it has six to seven body areas or organ systems."

According to NGS's original announcement, expanded problem-focused exams would require two to five body areas or organ systems, and detailed exams would require 6-7 body areas or organ systems.

Although the changes will not be mandated, "all medical records reviewed will be subject to the original standard of 2-7 or the newly suggested levels of 2-5 and 6-7, in whatever manner is more beneficial to our providers," according to the report.

This is similar to having the 1995 or the 1997 documentation guidelines to choose from, instead of the more recent ones only, according to Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh.

"The 6-7 body areas or organ systems is a guideline, not a requirement," Hauptman says. "But, it does give physicians a better understanding as to how the MAC might consider the documentation supporting the submitted claim."

NGS adds that these suggestions apply to services coded with the 1995 Documentation Guideline for E/M Services, not those coded with the 1997 Documentation Guidelines for E/M Services.

Reminder: NGS's Evaluation and Management Documentation Training Tool reflects the 2-7 exam component standard for both coding levels and will remain unchanged.