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1995 EXAM

Charlene Posted Wed 20th of March, 2019 09:39:38 AM
Can organ systems and body areas be counted together to calculate exam levels: problem focused, expanded problem focused, detailed and comprehensive? We're undergoing a voluntary audit and it is being advised that we add BA and OS together for all levels except comprehensive. The CMS 1995 guideline is being sited, and it does state, "expanded problem focused --a limited exam of the affect body area OR organ system AND other symptomatic OR related organ system(s). Detailed--an extended exam of the affected BA(s) AND other symptomatic OR related organ system(s). Our carrier is Palmetto and in a 2014 webinar they stated BA and OS could NOT be counted together. It also stated Palmetto would accept 8 BA OR OS for comprehensive exam.
SuperCoder Answered Fri 22nd of March, 2019 09:48:22 AM

Hi Charlene,

For billing you may use either version of the documentation guidelines for a patient encounter, not a combination of the two, (1995 or 1997).

The examination section of the 1995 score sheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record you can use either the body areas or the organ systems. If you combined the body areas and organ systems you would be giving credit twice which would be incorrect when determining the final score for the examination section of the score sheet.

The key to 1995 E/M guidelines exam level differences between EPF and detailed is if an extended exam of an affected body area/organ system was medically necessary, performed, and documented. The 1995 EM guidelines do not provide any more specifics than that. Many compliance depts therefore instead use the 1997 guidelines for their clarity. If you are auditing/coding for specialties that do not have specialty guidelines or very applicable ones to use (such as peds using 1997 general multisystem exam), we recommend that you audit a sample of exam records from the same provider and compare typical exam entries for level 3-5. See where you can separate detailed from EPF exam. Often, the provider can show a delineation between the two such as his usual cardio exam involves these items but an extended one includes these additional items. That definition should then be entered into your compliance plan. For any auditor, you should include the definition along with any requests for documentation. Feel free to ask for any further query.

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