Medicare Compliance & Reimbursement

Detailed exams to require 6-7 body areas or organ systems starting July 1.

If you find evaluation and management (E/M) expectations for expanded problem focused and detailed exams confusing, National Government Services (NGS) offers new modifications to expand and refine the process for providers covered by this Medicare Administrative Carrier. But whether you find the new guidance a help or a hindrance will depend on your specialty.

Discover Meaning of NGS Exam Requirement Change

According to its announcement, the NGS change to E/M expectations for expanded problem focused and detailed exams will be effective for services physicians perform on and after July 1, 2017.

Check out the following chart NGS included in its announcement:

NGS initiated this change because multiple providers have asked for clarification about the current requirements for expanded problem focused and detailed exams, says the announcement.

“Citing the same scope of examination for both levels has led to frequent provider confusion on documentation requirements and coding selections, as well as a degree of subjectivity in reviewing medical records for these services,” says NGS. “This change will eliminate the confusion and bring NGS into alignment with other CMS-sponsored review entities.”

Understand Differences Between 1995 vs. 1997 E/M Guidelines

To better see the full impact of the NGS exam requirement change, take a closer look at what the 1995 and 1997 Documentation Guidelines for E/M Services say.

Similarities: Both the 1995 and 1997 guidelines base the levels of E/M services on four types of exams: problem focused, expanded problem focused, detailed, and comprehensive.

Since the NGS announcement deals with expanded problem focused and detailed exams, see how the 1995 and 1997 guidelines define those types of exams:

Expanded Problem Focused — a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).

Detailed — an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).

Per both the 1995 and 1997 guidelines, an exam can involve either several organ systems or one single-organ system.

“The type and extent of the exam performed is based on clinical judgment, the patient’s history, and nature of the presenting problem(s),” say both sets of guidelines.

Differences: Although they share similarities, the 1995 and 1997 guidelines differ significantly when it comes to the E/M exam documentation requirements.

1995 Guidelines: According to the 1995 guidelines, the medical record for a general multi-system exam should include findings of eight or more organ systems.

1997 Guidelines: The 1997 guidelines describe the exam in more depth by differentiating between general multi-system and single-organ exams.

To see differences between requirements for general multi-system and single-organ system exams for expanded problem focused and detailed in the 1997 guidelines, check out the snippets below from charts in the E/M Services Guide.

Ask the Pros: How the NGS Change Impacts Coding

Our experts weigh in on how the NGS change will affect E/M claims.

“Having defined guidelines is such a relief,” says Suzan Hauptman, CPC, CEMC, CEDC, AAPC Fellow, senior principal at ACE Med Group in Pittsburgh. “Novitas Solutions has had a rule around this for a while now, and it’s nice to see the other contractors spelling it out.”

Hauptman adds to her thoughts about the new guidelines.

“The physicians providing detailed examinations will now feel confident that the examination they performed and documented is within the standard determined by the contractor,” says Hauptman. “However, those physicians who felt that their two-organ system exam was detailed in nature and documented as such could possibly find themselves downcoding services based on this new rule.”

Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Wash., also talks about how she sees the change impacting coders.

“This will be a significant change because the current requirements require not only 2-7 systems be examined, but for an EPF [expanded problem focused] exam, a limited exam of the affected body area or organ system, and for a detailed exam, 2-7 systems with an extended exam of the affected body area or organ system,” says Bucknam. “It is the ‘limited exam’ and ‘extended exam’ portion of the rule that causes so much confusion.”

The bottom line: The difference is now a provider won’t be able to use a 2-5 organ system exam with one being more detailed because the guidelines don’t allow for it, says Hauptman. If the note had, for example, the vital signs along with a brief cardiac examination, followed by a detailed gastrointestinal examination, it could have been a detailed exam. Now it’s an expanded problem focused exam.

These new requirements will have both a good and bad impact, according to Bucknam and Hauptman.

“On the good side, it will be much easier to get a detailed exam for some specialties,” says Bucknam. “If you document even a very brief exam of at least six systems, you will be able to bill the higher-level service.”

It will also be easy to count the exam elements and to know that your MAC agrees with that level of service, adds Bucknam.

However, the change will also have a negative impact, according to Bucknam.

“On the bad side, if you are in a specialty where you wouldn’t typically do an exam of lots of different parts of the body, but where you might do quite an extended exam of the specialty system and maybe one or two others, you won’t be able to bill a detailed exam using the 1995 rules,” says Bucknam. “Specialties like GI, cardiology, ophthalmology, dermatology, and others will be forced to use the 1997 specialty exams instead of the 1995 exams.”

Bucknam further explains her thoughts.

“The 1997 rules are quite specific; there are some elements that are simply not included in the 1997 single-system exams,” says Bucknam. “Providers in those specialties will have a steep learning curve to learn the requirements for the 1997 exams in order to bill the higher-level services.”

Check with your payers: This change applies to NGS customers only, so other MACs may follow different rules. You should always check to see what your MAC expects and what rules you should follow.