Oncology & Hematology Coding Alert

Be sure you choose the single set that's most advantageous to your code choice.

With two sets of guidelines -- 1995 and 1997　-- for assigning an E/M physical examination level, you may have a hard time keeping the requirements for each level straight.

Clip this chart from Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with UPMC in Pittsburgh, Pa., and keep it near your desk for quick access to the exam level details for office and outpatient visits.

Note: The 1997 column refers to the General Multi-System Exam (GMSE) requirements. Check the 1997 guidelines for additional details if you're reporting a single-organ system examination. Those exam requirements differ significantly. When applying 1997 guidelines, use the system that provides the greatest advantage for the physician, depending on the specialty and the examination performed and documented.

Also remember that the physical exam component is only one of the components to consider before you choose your final E/M code. You must apply a single set of guidelines (either 1995 or 1997) to all of the elements when you decide an encounter's E/M code (guidelines are available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp).

Final Tip: Use Templates With Caution

An additional tool your practice may consider to ease E/M coding is a template. Using a paper or electronic template within your electronic medical record (EMR) can help ensure the oncologist documents every piece of the physical exam portion of an office visit performed. But you'll need to take a few precautions if your office uses templates.

Train and tailor: "Templates are a good way to ensure capturing of all elements of the exam, but physician training can help with this also," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri,　Department of Surgery, in Columbia. "If you do use a template, it really is a good idea to tailor it to the specialty."

Review the full template: "Using templates can save time, but if providers aren't diligent in reviewing/updating each portion of the template for every visit it can cause severe errors in the medical record," says Kelly Loya, CPC-I, CHC, CPhT, managing consultant for Sinaiko Healthcare Consulting Inc., a division of Altegra Health, in Los Angeles. "Templates often contain enough for a comprehensive history and exam if needed. This is not medically necessary for all visits. Updating only the HPI [history of present illness] and MDM [medical decision making] without updating the templated elements performed and documented can cause conflicting and inaccurate information to be entered into the medical record."

Avoid upcoding: "Templates can be useful as long as they are not abused," agrees Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. "The appropriate exam is the exam that the physician thought was needed in order to appropriately assess the patient's presenting problem." Adding unnecessary information just to bump up the E/M level is inappropriate.

In other words, medical necessity must guide the exam. "The physician should document everything he needed to check in order to appropriately assess the patient's condition, but should not do 'extra' exam simply to meet a level of service," Bucknam says.

For more information: Check out "3 Questions Get to the Heart of Physical Exam Guideline Options" in Oncology & Hematology Coding Alert, vol. 13, no. 9, for additional information related to the physical exam element of E/M coding.