Pediatric Coding Alert

Question: We are performing a voluntary self-audit of our evaluation and management (E/M) codes. As preparation, we reviewed both the 1995 and 1997 guidelines. The 1995 guidelines for the first three levels of examination both note that we can count body areas or organ systems. My question is, can we add areas or systems together when we determine the level of exam?

Codify Subscriber

Answer: As you say, the 1995 guidelines for three of the four levels of exam providers can perform note that you can count either body areas or organ systems:

• 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).

However, in the 1995 guidelines, the Centers for Medicare and Medicaid Services (CMS) does not spell out how many body areas or organ systems count toward which level of exam for these first three levels. It is only when they get to the comprehensive exam that CMS gets specific and requires you to document “a general multi-system examination” involving “eight or more of the 12 organ systems” or a “complete examination of a single organ system.”

Even so, it is generally regarded that a problem-focused exam involves examining one area or system, while an expanded problem-focused exam would look at two-to-seven areas or systems, and a detailed exam would involve a detailed examination of one area or system along with a brief exam of one-to-six other areas or systems.

Though the guidelines do not address your question specifically, private payers and Medicare generally do not allow you to count both body areas and organ systems. The reason is simple: counting body areas and organ systems together would allow you to double-count exam elements and inflate the final score on the exam portion of the E/M score sheet.

As an example, consider an examination of a patient’s genitalia. You could count that as an examination of the genitalia, groin, and buttocks body area and an examination of the genitourinary organ system, giving you two points toward the exam when, in reality, your provider only performed one exam and should only be given credit for that.

(For links to the 1995 and 1997 guidelines, along with links to E/M scoresheets for the 1995 guidelines and various specialties, go to >www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00004968&_afrLoop=65916785092626#!@@?_afrLoop=65916785092626¢erWidth=100%&contentId=00004968&leftWidth=0%&rightWidth=0%&showFooter=false&showHeader=false&_adf.ctrl-state=xfjjqom8t_50.)