Wiki 95 Guidelines

Create Wiki
Z

zztoolzz

New
Messages
8
Location
Denver
Best answers
0
Can we use the entire office note to find HPI and ROS as long as we do not double dip?

For the 95 guidelines there are organ systems and body areas. If we do a full body exam which is listed out as each body part examined could we use all 10 body areas and that be a comprehensive exam? I see that it says 1 body area or organ system, 2-7 body systems, 8 or more body systems. Do you have to use the organ systems or do you have to use the organ systems with the body areas or can you just use the body areas? With the 97 guidelines it's hard for us to get a comprehensive exam so we are wondering if it may be easier to use the 95 guidelines.

If we have 10 body areas listed as examined (skin exam for dermatology) can we use that as a comprehensive exam using the 95 guidelines?
 
Last edited:
Yes, you can use the entire note for HPI/ROS - it does not have to specifically labeled as such.

Under 1995 guidelines, it must be 8 SYSTEMS, not body areas. The guidelines are very clear about this. So, in your example for skin/derm, it would be the integumentary organ system toward the eight required. Body areas can count toward EPF or detailed exams but not toward compreshensive.
 
In the 95 guidelines it says a comprehensive exam is a complete exam of a single organ system. Cant we use the skin as our organ system?
 
Now I am having trouble understanding your question. I took a look at the 97 guidelines for the skin examination - assuming the exam covers the HEENT and costitutional boxes, where are you having issues with acheiving the comprehensive exam? If you cannot get the 8 areas for the skin, how would you be examining the other organ systems required in 95? Or the better question would be what do your doctors consider a "complete" examination of the skin organ system?

Maybe an example would help - but again, then it would be just one person's opinion.
 
Here's my take on your 2 questions:

1) Lance has the right of it - you are allowed to get that info from anywhere in the note, it doesn't have to be labeled as ROS or HPI to get credit. However, be careful to make sure the info you are looking at is actually ROS. The ROS should be an inventory of body systems obtained through questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. By the nature of ROS this is subjective, obtained from the patient - not objective information determined during the physical examination.

2) The answer to your second question about a single-system comprehensive exam under the 95 guidelines is a bit more complex. Looking at the CMS definition of the 1995 guidelines, a Comprehensive exam is defined as a general multi-system examination or complete examination of a single organ system. That would seem to indicate that a complete skin exam could be considered a type of Comprehensive exam. Sadly, there is no further definition in the 1995 exam guidelines as to what is a 'complete' skin exam. That's one reason dermatologists, psychiatrists, neurologists, and other specialists complained and prompted the development of the 1997 exam guidelines. The 1997 guidelines describe in detail what the requirements are for a single organ system examination recognized by CPT.

So as you pointed out, what's wrong with going by the 1995 guidelines, and examining the skin in 10 different body areas? Why doesn't that count as a Comprehensive exam? Well, depending on your MAC you will have a different auditing tool. Where I live, NHIC is our MAC and their auditing tool is like most others in how it scores the 1995 physical exam. Here's how they spell it out:

  • Problem Focused - Limited exam of the affected body area or organ system
    1 (BA) or (OS)
  • Expanded Problem Focused - Limited exam of the affected body area or organ system and other symptomatic or related organ systems
    2-4 (OS) and/or (BA)
  • Detailed - Extended exam of affected body area(s) and other or related organ systems.
    5-7 (OS) and/or (BA)
  • Comprehensive - A general multisystem exam or complete exam of a single organ system
    8 or more (OS)

Notice how on the first 3 levels they count body areas (BA) or organ systems (OS) but for some reason on the comprehensive level they only count organ systems? I'm not sure why that is, but it isn't a typo. Perhaps your local carrier will allow body areas for a 1995 comprehensive exam, but I have yet to find one that will. The reason isn't exactly clear, as the CMS and CPT definitions both would seem to allow for a complete single organ system exam to be counted as Comprehensive, but no MACs seem to have a way of defining "complete" except for the 1997 exam definition.
 
You must log in or register to reply here.
Top