Primary Care Coding Alert

Physical exam element can point you to the better set.

Choosing whether to follow the 1995 or 1997 E/M coding guidelines can potentially boost your code level or prevent your physician for getting full credit for his work and reduce his legitimate reimbursement. If you sometimes wonder which set is better for your family physician's coding, focusing on how to tally your provider's physical exam documentation can be your key to success.

Grasp "Drill Down" Versus "Holistic" Distinction

Before jumping in too far, it's important to understand some basic differences between the guidelines.

1995: The 1995 guidelines are more physician-friendly and are less restrictive than the 1997 guidelines. They allow the physician to make any comment related to any organ system or body area he examines. Remember the physician gets the same amount of credit for examining a given organ system, no matter how much he or she does and documents in the exam of that system.

Here's a breakdown of what should be documented for each level of physical exam under the 1995 guidelines:

• Problem focused = 1 body system or area
• Expanded problem focused = 2-7 body systems or areas
• Detailed = 1 body system or area in greater detail and 1-6 brief system(s)
• Comprehensive = 8 or more body systems OR a complete single system exam.

Summing up: The 1995 version tends to be more multisystem oriented, which may make it more useful to the typical family physician practice.

1997: The 1997 guidelines include specific physical exam elements that must be addressed in the provider's documentation. Think of the '97 set as following a "bean counting" approach for each element of a system the provider addresses. The 1997 version specifies exam elements for a set of single system exams in addition to a general multisystem exam, which can be advantageous when the physician completes a thorough exam of a body system. However, if the physician addresses elements other than those specified in the guidelines, he will not necessarily receive credit for that element in the level of exam. A physician may get multiple points of credit for their documentation of a single organ system, all of which contributes to a potentially higher level of exam.

The general breakdown for physical exam requirements under the 1997 guidelines is:

• Problem focused = 1-5 bulleted elements in 1 or more organ systems
• Expanded problem focused = 6-11 bulleted elements in 1 or more organ systems
• Detailed = 12-17 bulleted elements in 2 organ systems in 2 or more organ systems
• Comprehensive = 18 or more bulleted elements from 9 or more systems or complete examination of a single system.

Watch for System Specifics to Choose Better Set

Which set of guidelines you use depends on the documentation at your practice, experts say.

"Typically, the 1995 guidelines are going to be more advantageous for most practices," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance and education for the University of Washington Physicians Compliance Program in Seattle. "This is because they're more flexible and because they reflect the way most physicians were taught to document. However, some physicians have been taught or may have developed good documentation practices around the 1997 guidelines, and this may be advantageous to them."

Lesson: Until a better system is in place, use the set of guidelines that is most beneficial for each encounter. "Some specialties will benefit from the use of 1995 rules, others will benefit from the use of the 1997," says Becky Boone, CPC, CUC, a certified reimbursement assistant in Columbia, Mo. "Make sure you look closely when making these changes in your practice."

Example: Mrs. Smith has a 5x8 mm callus on her right thumb. There is tenderness and fullness in the mid-pulp. She has full range-of-motion in that hand. Under the 1995 guidelines, the exam qualifies as expanded problem focused because the physician noted examination of 2 systems or areas (callus for the skin, full range-of-motion for musculoskeletal). Under the 1997 guidelines, you have a problem focused exam because the physician documented examination of 3 bulleted elements (2 skin elements for inspection and palpation of the callus, and 1 musculoskeletal element for the range-of-motion exam).

Switch Between Cases, Not Within a Case

Good news for coders is that you don't have to choose one set of guidelines and use it every time you report an E/M service.

"Given that, per Medicare, 'carriers and A/B Medicare Administrative Contractors are to continue reviews using both the 1995 and 1997 documentation guidelines (whichever is more advantageous to the physician),' physician practices are not restricted to using only one of the guidelines," says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver.

Plus: Private payers and Medicaid programs have uniformly adopted both the 1995 and 1997 guidelines as well.

Essential: The key is that you choose either the 1995 or the 1997 guidelines for a single encounter, and stick with it. And remember, the guidelines differ primarily in reporting the physical examination. The other two key components of the encounter -- history and medical decision making -- essentially remain the same, regardless of which physical examination guidelines you use. The one caveat is that the 1997 guidelines related to the history of present illness (HPI) include "the status of at least three chronic or inactive conditions" in the definition of an extended HPI; that language is absent from the 1995 guidelines.