Practice Management Alert

Question: I am so frustrated with the Palmetto GBA J1 Part B E/M Website because there is no clarity when it comes to the 95 exam guidelines for EPF and detailed. I am curious if some of you go by either:

EPF: 2-4 or 2-7
Detailed: 5-7 or 2-7

Can you help me determine the proper way to decide the exam level under 95 guidelines?

Georgia Subscriber

Answer: There are two sets of guidelines you should be familiar with before trying to determine the level of the physical examination key component for your E/M coding: 1995 and 1997 guidelines.

Both sets of guidelines help you determine which of the following four levels of examinations your provider completed during an E/M service: problem-focused, expanded problem focused, detailed, and comprehensive. Because the 1995 exam criteria are much less restrictive, some practices use this set of guidelines. But, as you say, there is a catch with 1995 – the guidelines aren’t very clear on the difference between an expanded problem-focused (EPF) and a detailed exam.

The key to 1995 EM guidelines exam level differences between EPF and detailed is if an extended exam of an affected body area/organ system was medically necessary, performed, and documented. The 1995 EM guidelines do not provide any more specifics than that. Many compliance departments, therefore, instead use the 1997 guidelines for better clarity.

If you are coding or performing an internal audit for specialties that do not have 1997 specialty-specific guidelines or that rely on the 1997 general multisystem exam guidelines (such as pediatric practices using 1997 general multisystem exam), experts recommend that you audit a sample of exam records from the same provider and compare typical exam entries for levels 3-5. See where you can find the key differences in what the provider actually does for a detailed exam versus an EPF exam. Often, the provider can show delineation between the two. In other words, you can define the exam levels because the provider’s usual exam of a system involves certain items but an extended/detailed exam includes certain additional items.

Then, you should document the provider’s self-defined EPF versus detailed exam definitions into your compliance plan. If you are ever audited by an outside entity, you should include those definitions along with any requests for documentation.