Are you using the right physical exam templates?

March 24, 2014

There are two accepted versions of the E&M documentation guidelines that have been released by the Centers for Medicare & Medicaid Services: one from 1995 and another from 1997. The main difference between the guidelines lies in the detail that surrounds the appropriate level of documentation for physical examination.

I heard from someone attending one of your seminars that systems and body areas have been considered differently in auditing charts for evaluation and management services. Can you explain this further?

There are two accepted versions of the E&M documentation guidelines that have been released by the Centers for Medicare & Medicaid Services: one from 1995 and another from 1997. The main difference between the guidelines lies in the detail that surrounds the appropriate level of documentation for physical examination.

The 1997 guidelines have a specific set of bullet points listed for several specialty examinations. The exams relevant to urology include the multi-system examination and the genitourinary system examination. Both examinations have specific systems and body areas lumped into a prescribed physical examination, with a list of elements for each system or body area. The 1997 guidelines require the use of the list of elements listed in the documentation guidelines, with responses indicating whether the examination reveals a normal or abnormal finding and, if abnormal, to provide specific documentation.

The 1997 guidelines for a comprehensive multi-system exam state:

  • Comprehensive examination: Should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.

The 1997 guidelines for a comprehensive specialty exam state:

  • Comprehensive examination: Should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.

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The 1995 guidelines, on the other hand, are not specific. There is no list included in the guidelines providing a check sheet for elements based on systems or body areas. However, the guidelines do include a list of organ systems and body areas as a guide. The list of body areas is as follows:

  • head, including the face

  • neck

  • chest, including breasts and axillae

  • abdomen

  • genitalia, groin, buttocks

  • back, including spine

  • each extremity.

The list of organ systems is:

  • constitutional (eg, vital signs, general appearance)

  • eyes

  • ears, nose, mouth, and throat

  • cardiovascular

  • respiratory

  • gastrointestinal

  • genitourinary

  • musculoskeletal

  • skin

  • neurologic

  • psychiatric

  • hematologic/lymphatic/immunologic.

The 1995 documentation guidelines indicate that a comprehensive physical examination requires the following documentation: “The medical record for a general multi-system examination should include findings about eight or more of the 12 organ systems.”

The interpretation we spoke about in the seminar was surrounding this portion of the guideline, and the confusion was created when using a 1997 template but scoring the visit with 1995 guidelines. Note above that the documentation guidelines only references organ systems and not body areas in the general multi-specialty examination. Of course, there is no documentation guideline for a specialty-specific examination in the 1995 guidelines.

Therefore, as stated, comments from eight organ systems (at least one per system) from the list above will be required to meet the requirements for a comprehensive physical examination. This means that those templates built using 1997 guidelines cannot count “head” and “neck” as organ systems, and a notation of “normal” for those body areas would not help in documenting a comprehensive physical examination. However, a notation under “neck” stating “lymph nodes normal” would be counted as one comment for the hematologic/lymphatic/immunologic organ system.

Audits are turning up in many states looking carefully at this aspect of documentation. Take care in designing your templates in both paper and electronic to avoid this mistake.UT

 

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The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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