E&M documentation: Two points you may be missing

October 1, 2005

Most urologists do not need a course in "E&M Documentation 101," but two specific documentation issues are worth clarifying.

1995 vs. 1997 guidelines

The 1995 and the 1997 guidelines, for all practical purposes, are the same for history and medical decision making. The big difference is in the physical exam. To refresh your memory, the different levels for a physical exam for the 1995 guidelines divided the exam into the examination of the affected organ system, the examination of a related organ system, and a complete exam.

Many of us switched to the 1997 guidelines when they came out because of the standardized bullets. We at Physician Reimbursement Systems were originally told that, in order to perform a complete exam using the 1995 guidelines, one had to have an extended exam (four or more examination points) for a minimum of eight systems. That changed 2 to 3 years ago. Medicare has instructed its auditors to check for one element in each of eight systems when auditing charts.

The use of the 1995 guidelines will allow you to reach a higher-level physical examination in a new patient with less work and documentation. This is true for both the second- and third-level new patient/consult codes. However, the real advantage is in performing a complete exam, which is required for a level four or five new patient or consult code.

Using the 1995 guidelines, a physician only has to examine eight body/ organ systems with one element each, and you can determine those examination points. Compare this with the 1997 guidelines, which required the complete genitourinary exam, with the shaded and unshaded areas, or the multi-system exam that required nine systems with at least two elements predetermined by the documentation guidelines, and you will see a significant difference.

Implementing the 1995 guidelines

The bottom line: It's easier to use the 1995 documentation guidelines. For those who have not attended one of the PRS or AUA seminars in the last 2 years and who may not have an updated pocket card and wall chart, Watson Pharmaceuticals will be delivering the latest version to your offices in the future. Ask your Watson sales representative for copies.