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Confusion 1995 E/M EPF and Detailed Exam

Leslie Posted Wed 01st of May, 2013 17:30:29 PM

I have a question that I can hope you can guide me. I am so frustrated with the Palmetto GBA J1 Part B E/M website, that there is no clarity when it comes to the 95 exam guidelines for EPF and Detailed.

I am curious if some of you go by either:

EPF: 2-4 or 2-7
Detailed: 5-7 or 2-7

I hope that someone can guide me with a more detailed answer.

SuperCoder Answered Tue 07th of May, 2013 12:11:51 PM

Hi there,

This is with my E/M Editor and she will respond you soon. Thanks for being patient.

SuperCoder Answered Wed 08th of May, 2013 20:37:16 PM

The key to 1995 EM 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), I 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.

Jen Godreau, CPC, CPMA, CPEDC

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