Urology Coding Alert

Planned change to Expanded Problem Focus, EPF, and detailed exams no longer considered mandatory.

If you submit claims to the Medicare Auditor Contractor National Government Services (NGS), pay attention: the agency has reversed its policy change for expanded problem-focused and detailed exams as part of E/M services.

The scoop: NGS previously announced that the changed expanded problem-focused and detailed exam requirements would be considered mandatory for physicians. That's no longer the case, thanks to the policy reversal.

"In my opinion, although the detailed exam representing six to seven body areas or organ systems is no longer mandatory, I suggest practices under NGS still follow this because it has less ambiguity than the alternative," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, Vice President at Stark Coding & Consulting LLC, in Shrewsbury, NJ. "On audit, the chart can easily be defended as documenting a detailed exam if it has six to seven body areas or organ systems."

According to NGS's original announcement, expanded problem-focused exams would require 2-5 body areas or organ systems, and detailed exams would require 6-7 body areas or organ systems.

Although the changes will not be mandated, "all medical records reviewed will be subject to the original standard of 2-7 or the newly suggested levels of 2-5 and 6-7, in whatever manner is more beneficial to our providers," according to the report.

This is similar to having the 1995 or the 1997 documentation guidelines to choose from, instead of the more recent ones only, according to Suzan Hauptman, MPM, CPC, CEMC, CEDC AAPC Fellow, senior principal of ACE Med in Pittsburgh.

"The 6-7 body areas or organ systems is a guideline, not a requirement," Hauptman says. "But, it does give physicians a better understanding as to how the MAC might consider the documentation supporting the submitted claim."

NGS adds that these suggestions apply to services coded with the 1995 Documentation Guideline for E/M Services, not those coded with the 1997 Documentation Guidelines for E/M Services.

Note:  NGS's Evaluation and Management Documentation Training Tool reflects the 2-7 exam components standard for both coding levels and will remain unchanged.

Using the 2 to 5 organ systems or body areas for an expanded problem focused physical examination and 6 to 7 organ systems or body areas for a detailed physical examination separates clearly the different requirements needed for each level of physical examination performed and helps remove any uncertainty of which level should be coded, notes Michael Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York, University Hospital and Medical School, Stony Brook, NY.