nyyankees
True Blue
Is there some clarification on what supports a Detailed Exam? Is it 2 areas that provide a certain amount of detail? Is there a guideline on the amount required for detailed? Thanks..
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Wiki Detailed Exam-Is there some
- Thread starter nyyankees
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Pam Warren
True Blue
Yours is the million dollar question. In fact, our MAC is so confused they have two E&M auditing tools available, they're both different and nobody can tell me what's the REAL one to use. Lovely.
So, here's what we've done on an internal basis.
EPF and Detailed both require 2-7 BA or OS (and you can mix/match). For detailed, one of those BAs or OS has to be 'in detail'. What's that, you ask?
We looked at the 1997 bullets for each OS, and also compared that to our Electronic health record to see what/how many bullets are possible. We also checked with our specialists regarding their specific OS, and asked "what do you consider a detailed exam". We used their response as well as the convention that if at least 1/2 of the bullets were identified in the exam, it was considered detailed.
Our MAC's audit tool (we have NHIC, Lord bless us) says, for detailed "Extended exam of affected BAs and other or related OSs". Oh, and if that wasn't confusing enough, one tool says 2-7 and the other says 5-7. No wonder I drink.
So to answer your question...NO, there is no clarification, no explanation, no standardization and no feedback from the MAC here in New England anyway. So we have this internal policy that is pretty conservative, in hopes that we've covered all our bases and are bullet proof in an audit. I always suggest that when CMS is murky, that you at least put together some sort of standardization in order to keep everyone on the same coding/auditing page.
So, here's what we've done on an internal basis.
EPF and Detailed both require 2-7 BA or OS (and you can mix/match). For detailed, one of those BAs or OS has to be 'in detail'. What's that, you ask?
We looked at the 1997 bullets for each OS, and also compared that to our Electronic health record to see what/how many bullets are possible. We also checked with our specialists regarding their specific OS, and asked "what do you consider a detailed exam". We used their response as well as the convention that if at least 1/2 of the bullets were identified in the exam, it was considered detailed.
Our MAC's audit tool (we have NHIC, Lord bless us) says, for detailed "Extended exam of affected BAs and other or related OSs". Oh, and if that wasn't confusing enough, one tool says 2-7 and the other says 5-7. No wonder I drink.
So to answer your question...NO, there is no clarification, no explanation, no standardization and no feedback from the MAC here in New England anyway. So we have this internal policy that is pretty conservative, in hopes that we've covered all our bases and are bullet proof in an audit. I always suggest that when CMS is murky, that you at least put together some sort of standardization in order to keep everyone on the same coding/auditing page.
MikeEnos
Guest
No, it isn't defined by CPT. They just describe it as An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
Fortunately you can check with your local MAC for guidance, since they usually have an auditing tool so you can see what their requirements are. Since you are in New York, I believe your MAC is National Government Services, and they have released an audit tool that shows that they treat a Detailed exam as being an exam that documents findings in 6 or 7 body areas or organ systems. Where I live, NHIC is our MAC, and they require 5 to 7 body areas or organ systems. So it isn't defined in CPT, look to your local MAC for guidance. I've never seen a private insurance that has its own policy, I think they normally just defer to Medicare.
Fortunately you can check with your local MAC for guidance, since they usually have an auditing tool so you can see what their requirements are. Since you are in New York, I believe your MAC is National Government Services, and they have released an audit tool that shows that they treat a Detailed exam as being an exam that documents findings in 6 or 7 body areas or organ systems. Where I live, NHIC is our MAC, and they require 5 to 7 body areas or organ systems. So it isn't defined in CPT, look to your local MAC for guidance. I've never seen a private insurance that has its own policy, I think they normally just defer to Medicare.
nyyankees
True Blue
Thank you for the insight. NGS states 2-7 for Detailed which is what we have been using.
Tonyj
True Blue
My 2 cents.
NGS updated their audit tool a couple of years ago to state 5-7 for detailed (was 2-7). My MAC is Novitas and they go by the 4x4 rule for detailed. I just attended a seminar for CPMA where that same question came up and as per the instructor (it's not stated anywhere but..) if the physician would document more than (1) comment in the PE under BA/OS specific to the CC then it would/could qualify as a detailed exam.
e.g. CC: abdominal pain; PE-Abdomen: Soft, nondistended. obese abdomen. No palpable masses. She has no hepatosplenomegaly. (Of course in addition to the other 6 BA's or O/S')
nyyankees
True Blue
interesting. I pulled the E/M Tool and it had 2-7. Will double check. Thanks.
MnTwins29
True Blue
I am NY and tried to find this audit tool that stated 6 or 7 OS/BA for detailed and couldn't find it at NGS either.
Tonyj
True Blue
I misquoted my previous response. The correction is 6-7 for detailed. I have a powerpoint presentation from a NGS E/M seminar I attended in 2011 that specifically states 6-7 for detailed exam. Unfortunately, I couldn't paste it to this message but if you'd like I'd be more than willing to send it to your email if you provide it.
MnTwins29
True Blue
MikeEnos
Guest
Here is the link to the 2011 NGS Evaluation and Management Services Audit Tool for anyone interested.
nyyankees
True Blue
Tonyj
True Blue
See Mike Enos link. Thanks Mike!
rda23@aol.com
Guest
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And just to muddy the waters further, the Evaluation Sheet we grew up with here (using OS as the coin of the realm) shows it as "EPF: 2-4; Detailed: 5-7."