Wiki Does this meet Comprehesive 95 Exam?

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AR2728

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Vitals reviewed (noted early in note)
HEENT- pupils equal, round, reactive to light and accomodation
Neck Supple
Chest Clear
CV RRR
Abd Soft
Ext no c/c/e (assuming this is clubbing/cyanosis/edema-can he do that)
Gen WN/WD NAD

He wants to bill as comprehesive
 
Not at all

No, I don't see a comprehensive exam here under either 95 or 97 guidelines.

You need to have at least 8 systems or body areas for 95 guidelines - At the most I see 5 - Constitutional (Vitals and General Appearance), Eyes, Respiritory (Chest), CV, & GI. The neck exam does not fall under a system (unless he had mentioned the lymph nodes) - that is a body area only. I would consider the notes under extremities as CV, not Musculatory, but even if you count clubbing towards muscularskeletal, you still don't make 8. Under 97 guidelines you definetly don't have enough for a Comprehensive exam. This would acutally be more on the end of an Expanded Problem Focused Exam since he did not go into detail on any of the systems documented.

Hope this helps!
 
Epf

I wouldn't even bill it as detailed without knowing what the "affected body area / organ system" is .... for a Detailed exam under 1995 guidelines you have to have "an expanded exam of the affected body area / organ system" plus related organ systems. There is no evidence in this documentation of an expanded exam of any systems/body area.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
As per NGS Medicare, it qualifies for detailed exam.

The following are the excerpts from the webinar "Assessing Your Evaluation & Management Services Documentation" by NGS Medicare on Apr 26 2011. You can find the information from the "attachments for this event" area on their website.



Q3. What exactly is required for an expanded problem focused exam using the 1995 E/M guidelines? Can I use body areas and/or organ systems? How many are needed?

A: According to the documentation guidelines, an expanded problem focused exam is a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). At this level, using the ’95 Guidelines 2-5 body areas or organ systems must be documented. You may use either body areas or organ systems in all levels except the comprehensive. At the comprehensive level, only organ systems are accepted


Q4. What exactly is required in terms of the number of body areas and/or organ systems to qualify for a detailed exam using the 1995 E/M guidelines?

A: According to the documentation guidelines, a detailed exam is an extended examination of the affected body area(s) and other symptomatic or related organ system(s).At this level, using the ’95 Guidelines, 6-7 body areas or organ systems must be documented. You may use either body areas or organ systems in all levels except the comprehensive. At the comprehensive level, only organ systems are accepted.
 
It definitely does not meet the guidelines of a comprehensive exam. I agree with F Tessa; I see no extended exam or elaboration of any BA or OS for a detailed exam.
 
It depends on the payors. As per the definition of detailed exam (1995 DG) it may/may not suffice for the detailed exam but as per NGS Medicare it is okay.
 
Can you clarify what is an extended exam? how many notations from an organ system should be documented to say it is extended? 2,3,4....???
 
Jagadish said:
As per NGS Medicare, it qualifies for detailed exam.

The following are the excerpts from the webinar "Assessing Your Evaluation & Management Services Documentation" by NGS Medicare on Apr 26 2011. You can find the information from the "attachments for this event" area on their website.



Q3. What exactly is required for an expanded problem focused exam using the 1995 E/M guidelines? Can I use body areas and/or organ systems? How many are needed?

A: According to the documentation guidelines, an expanded problem focused exam is a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). At this level, using the ’95 Guidelines 2-5 body areas or organ systems must be documented. You may use either body areas or organ systems in all levels except the comprehensive. At the comprehensive level, only organ systems are accepted


Q4. What exactly is required in terms of the number of body areas and/or organ systems to qualify for a detailed exam using the 1995 E/M guidelines?

A: According to the documentation guidelines, a detailed exam is an extended examination of the affected body area(s) and other symptomatic or related organ system(s).At this level, using the ’95 Guidelines, 6-7 body areas or organ systems must be documented. You may use either body areas or organ systems in all levels except the comprehensive. At the comprehensive level, only organ systems are accepted.
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I have recently been told by the consultant firm that does our auditing, that they are looking at it more like 2-4 BA/OS and 5-7 BA/OG, instead of 2-5 & 6-7. I also heard that the auditors will be looking more closely in the future at the first column in the MDM table of risk vs the third column, which is overused they feel due to the patient just receiving a prescription. The latter has yet to be presented to me in writing, so I am waiting to see that in writing for myself before I change my way of coding, as I code ER's and we manage a lot of prescriptions. I just thought you might like to know that info, as it did help me to look more closely at how many BA/OS that are reveiwed in each exam. Hope this is helpful:)
 
Thanks to all for your replies! I agree his exam is seriously lacking to bill as comprehensive. However, when approaching a physician regarding his E&M levels, I have found it is best to get insight from others before discussing the subject.

-April
 
NGS 1995 exam requirements

Industry norm has always been 2 to 4 for EPF and 5 to 7 for Detailed, but NGS came out this year stating that they require 6 to 7 for a Detailed Exam and indicated in the post from Jagadish. This makes it hard for physicians to keep strauight when commercial payers will typically recognize 5 to 7 for a Detailed Exam.
 
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