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Exam Guidelines
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Carol Pohlig

The extent of the exam should correspond to the nature of the presenting problem, the standard of care, and the physicians’ clinical judgment. Remember, medical necessity issues can arise if the physician performs and submits a claim for a comprehensive service involving a self-limiting problem. The easiest way to demonstrate the medical necessity for evaluation and management (E/M) services is through medical decision-making. It prevents a third party from making accusations that a Level 5 service was reported solely based upon a comprehensive history and examination that was not warranted by the patient’s presenting problem (e.g. the common cold).1

1995 Exam Guidelines

The 1995 guidelines differentiate 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory, gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).2 Physicians are permitted to perform and comment without mandate, as appropriate, but with a few minor directives:

  • Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems.

  • Elaborate abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

1997 Documentation Guidelines

The 1997 guidelines are formatted as organ systems with corresponding, bulleted items referred to as “elements.”3 Additionally, a few elements have a numeric requirement to be achieved before satisfying the documentation of that particular element. For example, credit for the “vital signs element” (located within the constitutional system) is only awarded after documentation of three individual measurements (e.g. blood pressure, heart rate, and respiratory rate). Failure to document the specified criterion (e.g. two measurements: “blood pressure and heart rate only,” or a single nonspecific comment: “vital signs stable”) leads to failure to assign credit.

Take note that these specified criterion do not resonate within the 1995 guidelines. Numerical requirements also are indicated for the lymphatic system. The physician must examine and document findings associated with two or more lymphatic areas (e.g. “no lymphadenopathy noted in the neck or axillae”).

In the absence of numeric criterion, some elements contain multiple components, which require documentation of at least one component. For example, one listed psychiatric element designates the assessment of the patient’s “mood and affect.” The physician receives credit for a comment regarding the patient’s mood (e.g. “appears depressed”) without identification of a flat (or normal).

click for large version
Table 1. Exam-level determination and appropriate assignment of care codes5

The 1997 Documentation Guide-lines comprise the following systems and elements:

Constitutional

  • Measurement of any three of the following seven vital signs:

    1. Sitting or standing blood pressure;

    2. Supine blood pressure;

    3. Pulse rate and regularity;

    4. Respiration;

    5. Temperature;

    6. Height; or

    7. Weight (can be measured and recorded by ancillary staff).

  • General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming)

Eyes

  • Inspection of conjunctivae and lids;

  • Examination of pupils and irises (e.g. reaction to light and accommodation, size, symmetry); and

  • Ophthalmoscopic examination of optic discs (e.g. size, C/D ratio, appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages).

 

 

click for large version
Table 2A: 1995 Documentation Guidelines2

click for large version
Table 2B: 1997 Documentation Guidelines2

Ears, Nose, Mouth, and Throat

  • External inspection of ears and nose (e.g. overall appearance, scars, lesions, masses);

  • Otoscopic examination of external auditory canals and tympanic membranes;

  • Assessment of hearing (e.g. whispered voice, finger rub, tuning fork);

  • Inspection of nasal mucosa, septum, and turbinates;

  • Inspection of lips, teeth, and gums; and

  • Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

  • Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus); and

  • Examination of thyroid (e.g. enlargement, tenderness, mass).

Respiratory

  • Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement);

  • Percussion of chest (e.g. dullness, flatness, hyperresonance);

  • Palpation of chest (e.g. tactile fremitus); and

  • Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs).

Cardiovascular

  • Palpation of heart (e.g. location, size, thrills);

  • Auscultation of heart with notation of abnormal sounds and murmurs; and

  • Examination of:

    • Carotid arteries (e.g. pulse amplitude, bruits);

    • Abdominal aorta (e.g. size, bruits);

    • Femoral arteries (e.g. pulse amplitude, bruits);

    • Pedal pulses (e.g. pulse amplitude); and

    • Extremities for edema and/or varicosities.

Chest

  • Inspection of breasts (e.g. symmetry, nipple discharge); and

  • Palpation of breasts and axillae (e.g. masses or lumps, tenderness).

Gastrointestinal

  • Examination of abdomen with notation of presence of masses or tenderness;

  • Examination of liver and spleen;

  • Examination for presence or absence of hernia;

  • Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, and rectal masses; and

  • Obtain stool sample for occult blood test when indicated.

Minimum requirements not met

Upon admission to the hospitalist service, a 64-year-old female presents with uncontrolled diabetes mellitus resulting in hyperglycemia. The hospitalist performs a complete exam, but documentation only reflects an expanded, problem-focused exam (with respect to both the 1995 and 1997 guidelines).

An expanded, problem-focused exam does not satisfy the minimum requirements for initial hospital care (99221) (see Table 1).4 While some reviewers could say that this service should not be reported (i.e. not billed), because the minimum requirements were not met, CMS has clarified this in a recent transmittal, allowing the physician to report a subsequent hospital care code (99231-99233) that best corresponds to the provided documentation.5 Explicitly stated, “Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.”5

Genitourinary (Male)

  • Examination of the scrotal contents (e.g. hydrocele, spermatocele, tenderness of cord, testicular mass);

  • Examination of the penis; and

  • Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).

Genitourinary (Female)

  • Pelvic examination (with or without specimen collection for smears and cultures), including:

    • Examination of external genitalia (e.g. general appearance, hair distribution, lesions) and vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);

    • Examination of urethra (e.g. masses, tenderness, scarring);

    • Examination of bladder (e.g. fullness, masses, tenderness);

    • Cervix (e.g. general appearance, lesions, discharge);

    • Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support); and

    • Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).

 

 

  • Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.

Musculoskeletal

  • Examination of gait and station;

  • Inspection and/or palpation of digits and nails (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);

  • Examination of joints, bones and muscles of one or more of the following six areas:

    1. head and neck;

    2. spine, ribs and pelvis;

    3. right upper extremity;

    4. left upper extremity;

    5. right lower extremity; and

    6. left lower extremity.

The examination of a given area includes:

  • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;

  • Assessment of range of motion with notation of any pain, crepitation or contracture;

  • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and

  • Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

  • Inspection of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers); and

  • Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening).

Neurologic

  • Test cranial nerves with notation of any deficits;

  • Examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski); and

  • Examination of sensation (e.g. by touch, pin, vibration, proprioception).

Psychiatric

  • Description of patient’s judgment and insight;

  • Brief assessment of mental status, including:

    • Orientation to time, place, and person;

    • Recent and remote memory; and

    • Mood and affect (e.g. depression, anxiety, agitation).

Considerations

The 1997 Documentation Guidelines often are criticized for their “specific” nature. Although this assists the auditor, it hinders the physician. The consequence is difficulty and frustration with remembering the explicit comments and number of elements associated with each level of exam. As a solution, consider documentation templates—paper or electronic—that incorporate cues and prompts for normal exam findings with adequate space for elaboration of abnormal findings.

Remember that both sets of guidelines apply to visit level selection, and physicians may utilize either set when documenting their services. Auditors will review documentation with each of the guidelines, and assign the final audited result as the highest visit level supported during the comparison. Physicians should use the set that is best for their patients, practice, and peace of mind.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

  1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, Ill.: American College of Chest Physicians; 2009:87-118.

  2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Sept. 12, 2011.

  3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Sept. 12, 2011.

  4. Highmark Medicare Services. Frequently Asked Questions: Evaluation And Management Services (Part B). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#10. Accessed Sept. 14, 2011.

  5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at: http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Sept. 15, 2011.

  6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

 

 

Determining Levels of Exam

A reviewer assigns one of four exam levels. As with the history component, documentation must meet the requirements for a particular level of exam before assigning it to any visit category (see Table 1). The requirements vary greatly between the 1995 and 1997 guidelines. The four recognized levels of history are problem-focused, expanded problem-focused, detailed, and comprehensive (see Table 2A and 2B). Similar to the history component, a few visit categories do not have associated exam levels or documentation requirements for exam elements, such as critical care and discharge day management.

As counting the number of exam elements seems rather straightforward, the most problematic feature of the 1995 guidelines involves “detailed” exam description. Overlap exists between the “detailed” and “expanded problem-focused” exam requirements. Both call for the notation of 2-7 systems/areas, but the detailed exam requires an “extended exam of the affected system/area related to the presenting problem.” Without further guidance from CMS, inconsistency flourishes. Documentation, review, and audit of the detailed exam become arbitrary.

Consider this cardiovascular exam example: “regular rate and rhythm; normal S1, S2; no jugular venous distention; no murmur, gallop or rub; peripheral pulses intact; no edema noted. Lungs clear.” Assigned credit is subject to clinical inference. Although most Medicare contractors attempt to avoid confusion and default to the 1997 requirements for a detailed exam, others attempt to define it.3 Highmark Medicare Services has uniquely developed the 4x4 tool (detailed exam=documentation of four elements examined in four body areas or four organ systems) in hopes of proper and consistent implementation of the evaluation and management (E/M) guidelines.4

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Carol Pohlig
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Carol Pohlig

The extent of the exam should correspond to the nature of the presenting problem, the standard of care, and the physicians’ clinical judgment. Remember, medical necessity issues can arise if the physician performs and submits a claim for a comprehensive service involving a self-limiting problem. The easiest way to demonstrate the medical necessity for evaluation and management (E/M) services is through medical decision-making. It prevents a third party from making accusations that a Level 5 service was reported solely based upon a comprehensive history and examination that was not warranted by the patient’s presenting problem (e.g. the common cold).1

1995 Exam Guidelines

The 1995 guidelines differentiate 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory, gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).2 Physicians are permitted to perform and comment without mandate, as appropriate, but with a few minor directives:

  • Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems.

  • Elaborate abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

1997 Documentation Guidelines

The 1997 guidelines are formatted as organ systems with corresponding, bulleted items referred to as “elements.”3 Additionally, a few elements have a numeric requirement to be achieved before satisfying the documentation of that particular element. For example, credit for the “vital signs element” (located within the constitutional system) is only awarded after documentation of three individual measurements (e.g. blood pressure, heart rate, and respiratory rate). Failure to document the specified criterion (e.g. two measurements: “blood pressure and heart rate only,” or a single nonspecific comment: “vital signs stable”) leads to failure to assign credit.

Take note that these specified criterion do not resonate within the 1995 guidelines. Numerical requirements also are indicated for the lymphatic system. The physician must examine and document findings associated with two or more lymphatic areas (e.g. “no lymphadenopathy noted in the neck or axillae”).

In the absence of numeric criterion, some elements contain multiple components, which require documentation of at least one component. For example, one listed psychiatric element designates the assessment of the patient’s “mood and affect.” The physician receives credit for a comment regarding the patient’s mood (e.g. “appears depressed”) without identification of a flat (or normal).

click for large version
Table 1. Exam-level determination and appropriate assignment of care codes5

The 1997 Documentation Guide-lines comprise the following systems and elements:

Constitutional

  • Measurement of any three of the following seven vital signs:

    1. Sitting or standing blood pressure;

    2. Supine blood pressure;

    3. Pulse rate and regularity;

    4. Respiration;

    5. Temperature;

    6. Height; or

    7. Weight (can be measured and recorded by ancillary staff).

  • General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming)

Eyes

  • Inspection of conjunctivae and lids;

  • Examination of pupils and irises (e.g. reaction to light and accommodation, size, symmetry); and

  • Ophthalmoscopic examination of optic discs (e.g. size, C/D ratio, appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages).

 

 

click for large version
Table 2A: 1995 Documentation Guidelines2

click for large version
Table 2B: 1997 Documentation Guidelines2

Ears, Nose, Mouth, and Throat

  • External inspection of ears and nose (e.g. overall appearance, scars, lesions, masses);

  • Otoscopic examination of external auditory canals and tympanic membranes;

  • Assessment of hearing (e.g. whispered voice, finger rub, tuning fork);

  • Inspection of nasal mucosa, septum, and turbinates;

  • Inspection of lips, teeth, and gums; and

  • Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

  • Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus); and

  • Examination of thyroid (e.g. enlargement, tenderness, mass).

Respiratory

  • Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement);

  • Percussion of chest (e.g. dullness, flatness, hyperresonance);

  • Palpation of chest (e.g. tactile fremitus); and

  • Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs).

Cardiovascular

  • Palpation of heart (e.g. location, size, thrills);

  • Auscultation of heart with notation of abnormal sounds and murmurs; and

  • Examination of:

    • Carotid arteries (e.g. pulse amplitude, bruits);

    • Abdominal aorta (e.g. size, bruits);

    • Femoral arteries (e.g. pulse amplitude, bruits);

    • Pedal pulses (e.g. pulse amplitude); and

    • Extremities for edema and/or varicosities.

Chest

  • Inspection of breasts (e.g. symmetry, nipple discharge); and

  • Palpation of breasts and axillae (e.g. masses or lumps, tenderness).

Gastrointestinal

  • Examination of abdomen with notation of presence of masses or tenderness;

  • Examination of liver and spleen;

  • Examination for presence or absence of hernia;

  • Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, and rectal masses; and

  • Obtain stool sample for occult blood test when indicated.

Minimum requirements not met

Upon admission to the hospitalist service, a 64-year-old female presents with uncontrolled diabetes mellitus resulting in hyperglycemia. The hospitalist performs a complete exam, but documentation only reflects an expanded, problem-focused exam (with respect to both the 1995 and 1997 guidelines).

An expanded, problem-focused exam does not satisfy the minimum requirements for initial hospital care (99221) (see Table 1).4 While some reviewers could say that this service should not be reported (i.e. not billed), because the minimum requirements were not met, CMS has clarified this in a recent transmittal, allowing the physician to report a subsequent hospital care code (99231-99233) that best corresponds to the provided documentation.5 Explicitly stated, “Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.”5

Genitourinary (Male)

  • Examination of the scrotal contents (e.g. hydrocele, spermatocele, tenderness of cord, testicular mass);

  • Examination of the penis; and

  • Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).

Genitourinary (Female)

  • Pelvic examination (with or without specimen collection for smears and cultures), including:

    • Examination of external genitalia (e.g. general appearance, hair distribution, lesions) and vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);

    • Examination of urethra (e.g. masses, tenderness, scarring);

    • Examination of bladder (e.g. fullness, masses, tenderness);

    • Cervix (e.g. general appearance, lesions, discharge);

    • Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support); and

    • Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).

 

 

  • Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.

Musculoskeletal

  • Examination of gait and station;

  • Inspection and/or palpation of digits and nails (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);

  • Examination of joints, bones and muscles of one or more of the following six areas:

    1. head and neck;

    2. spine, ribs and pelvis;

    3. right upper extremity;

    4. left upper extremity;

    5. right lower extremity; and

    6. left lower extremity.

The examination of a given area includes:

  • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;

  • Assessment of range of motion with notation of any pain, crepitation or contracture;

  • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and

  • Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

  • Inspection of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers); and

  • Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening).

Neurologic

  • Test cranial nerves with notation of any deficits;

  • Examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski); and

  • Examination of sensation (e.g. by touch, pin, vibration, proprioception).

Psychiatric

  • Description of patient’s judgment and insight;

  • Brief assessment of mental status, including:

    • Orientation to time, place, and person;

    • Recent and remote memory; and

    • Mood and affect (e.g. depression, anxiety, agitation).

Considerations

The 1997 Documentation Guidelines often are criticized for their “specific” nature. Although this assists the auditor, it hinders the physician. The consequence is difficulty and frustration with remembering the explicit comments and number of elements associated with each level of exam. As a solution, consider documentation templates—paper or electronic—that incorporate cues and prompts for normal exam findings with adequate space for elaboration of abnormal findings.

Remember that both sets of guidelines apply to visit level selection, and physicians may utilize either set when documenting their services. Auditors will review documentation with each of the guidelines, and assign the final audited result as the highest visit level supported during the comparison. Physicians should use the set that is best for their patients, practice, and peace of mind.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

  1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, Ill.: American College of Chest Physicians; 2009:87-118.

  2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Sept. 12, 2011.

  3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Sept. 12, 2011.

  4. Highmark Medicare Services. Frequently Asked Questions: Evaluation And Management Services (Part B). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#10. Accessed Sept. 14, 2011.

  5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at: http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Sept. 15, 2011.

  6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

 

 

Determining Levels of Exam

A reviewer assigns one of four exam levels. As with the history component, documentation must meet the requirements for a particular level of exam before assigning it to any visit category (see Table 1). The requirements vary greatly between the 1995 and 1997 guidelines. The four recognized levels of history are problem-focused, expanded problem-focused, detailed, and comprehensive (see Table 2A and 2B). Similar to the history component, a few visit categories do not have associated exam levels or documentation requirements for exam elements, such as critical care and discharge day management.

As counting the number of exam elements seems rather straightforward, the most problematic feature of the 1995 guidelines involves “detailed” exam description. Overlap exists between the “detailed” and “expanded problem-focused” exam requirements. Both call for the notation of 2-7 systems/areas, but the detailed exam requires an “extended exam of the affected system/area related to the presenting problem.” Without further guidance from CMS, inconsistency flourishes. Documentation, review, and audit of the detailed exam become arbitrary.

Consider this cardiovascular exam example: “regular rate and rhythm; normal S1, S2; no jugular venous distention; no murmur, gallop or rub; peripheral pulses intact; no edema noted. Lungs clear.” Assigned credit is subject to clinical inference. Although most Medicare contractors attempt to avoid confusion and default to the 1997 requirements for a detailed exam, others attempt to define it.3 Highmark Medicare Services has uniquely developed the 4x4 tool (detailed exam=documentation of four elements examined in four body areas or four organ systems) in hopes of proper and consistent implementation of the evaluation and management (E/M) guidelines.4

The extent of the exam should correspond to the nature of the presenting problem, the standard of care, and the physicians’ clinical judgment. Remember, medical necessity issues can arise if the physician performs and submits a claim for a comprehensive service involving a self-limiting problem. The easiest way to demonstrate the medical necessity for evaluation and management (E/M) services is through medical decision-making. It prevents a third party from making accusations that a Level 5 service was reported solely based upon a comprehensive history and examination that was not warranted by the patient’s presenting problem (e.g. the common cold).1

1995 Exam Guidelines

The 1995 guidelines differentiate 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory, gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).2 Physicians are permitted to perform and comment without mandate, as appropriate, but with a few minor directives:

  • Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems.

  • Elaborate abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

1997 Documentation Guidelines

The 1997 guidelines are formatted as organ systems with corresponding, bulleted items referred to as “elements.”3 Additionally, a few elements have a numeric requirement to be achieved before satisfying the documentation of that particular element. For example, credit for the “vital signs element” (located within the constitutional system) is only awarded after documentation of three individual measurements (e.g. blood pressure, heart rate, and respiratory rate). Failure to document the specified criterion (e.g. two measurements: “blood pressure and heart rate only,” or a single nonspecific comment: “vital signs stable”) leads to failure to assign credit.

Take note that these specified criterion do not resonate within the 1995 guidelines. Numerical requirements also are indicated for the lymphatic system. The physician must examine and document findings associated with two or more lymphatic areas (e.g. “no lymphadenopathy noted in the neck or axillae”).

In the absence of numeric criterion, some elements contain multiple components, which require documentation of at least one component. For example, one listed psychiatric element designates the assessment of the patient’s “mood and affect.” The physician receives credit for a comment regarding the patient’s mood (e.g. “appears depressed”) without identification of a flat (or normal).

click for large version
Table 1. Exam-level determination and appropriate assignment of care codes5

The 1997 Documentation Guide-lines comprise the following systems and elements:

Constitutional

  • Measurement of any three of the following seven vital signs:

    1. Sitting or standing blood pressure;

    2. Supine blood pressure;

    3. Pulse rate and regularity;

    4. Respiration;

    5. Temperature;

    6. Height; or

    7. Weight (can be measured and recorded by ancillary staff).

  • General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming)

Eyes

  • Inspection of conjunctivae and lids;

  • Examination of pupils and irises (e.g. reaction to light and accommodation, size, symmetry); and

  • Ophthalmoscopic examination of optic discs (e.g. size, C/D ratio, appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages).

 

 

click for large version
Table 2A: 1995 Documentation Guidelines2

click for large version
Table 2B: 1997 Documentation Guidelines2

Ears, Nose, Mouth, and Throat

  • External inspection of ears and nose (e.g. overall appearance, scars, lesions, masses);

  • Otoscopic examination of external auditory canals and tympanic membranes;

  • Assessment of hearing (e.g. whispered voice, finger rub, tuning fork);

  • Inspection of nasal mucosa, septum, and turbinates;

  • Inspection of lips, teeth, and gums; and

  • Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

  • Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus); and

  • Examination of thyroid (e.g. enlargement, tenderness, mass).

Respiratory

  • Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement);

  • Percussion of chest (e.g. dullness, flatness, hyperresonance);

  • Palpation of chest (e.g. tactile fremitus); and

  • Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs).

Cardiovascular

  • Palpation of heart (e.g. location, size, thrills);

  • Auscultation of heart with notation of abnormal sounds and murmurs; and

  • Examination of:

    • Carotid arteries (e.g. pulse amplitude, bruits);

    • Abdominal aorta (e.g. size, bruits);

    • Femoral arteries (e.g. pulse amplitude, bruits);

    • Pedal pulses (e.g. pulse amplitude); and

    • Extremities for edema and/or varicosities.

Chest

  • Inspection of breasts (e.g. symmetry, nipple discharge); and

  • Palpation of breasts and axillae (e.g. masses or lumps, tenderness).

Gastrointestinal

  • Examination of abdomen with notation of presence of masses or tenderness;

  • Examination of liver and spleen;

  • Examination for presence or absence of hernia;

  • Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, and rectal masses; and

  • Obtain stool sample for occult blood test when indicated.

Minimum requirements not met

Upon admission to the hospitalist service, a 64-year-old female presents with uncontrolled diabetes mellitus resulting in hyperglycemia. The hospitalist performs a complete exam, but documentation only reflects an expanded, problem-focused exam (with respect to both the 1995 and 1997 guidelines).

An expanded, problem-focused exam does not satisfy the minimum requirements for initial hospital care (99221) (see Table 1).4 While some reviewers could say that this service should not be reported (i.e. not billed), because the minimum requirements were not met, CMS has clarified this in a recent transmittal, allowing the physician to report a subsequent hospital care code (99231-99233) that best corresponds to the provided documentation.5 Explicitly stated, “Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.”5

Genitourinary (Male)

  • Examination of the scrotal contents (e.g. hydrocele, spermatocele, tenderness of cord, testicular mass);

  • Examination of the penis; and

  • Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).

Genitourinary (Female)

  • Pelvic examination (with or without specimen collection for smears and cultures), including:

    • Examination of external genitalia (e.g. general appearance, hair distribution, lesions) and vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);

    • Examination of urethra (e.g. masses, tenderness, scarring);

    • Examination of bladder (e.g. fullness, masses, tenderness);

    • Cervix (e.g. general appearance, lesions, discharge);

    • Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support); and

    • Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).

 

 

  • Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.

Musculoskeletal

  • Examination of gait and station;

  • Inspection and/or palpation of digits and nails (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);

  • Examination of joints, bones and muscles of one or more of the following six areas:

    1. head and neck;

    2. spine, ribs and pelvis;

    3. right upper extremity;

    4. left upper extremity;

    5. right lower extremity; and

    6. left lower extremity.

The examination of a given area includes:

  • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;

  • Assessment of range of motion with notation of any pain, crepitation or contracture;

  • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and

  • Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

  • Inspection of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers); and

  • Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening).

Neurologic

  • Test cranial nerves with notation of any deficits;

  • Examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski); and

  • Examination of sensation (e.g. by touch, pin, vibration, proprioception).

Psychiatric

  • Description of patient’s judgment and insight;

  • Brief assessment of mental status, including:

    • Orientation to time, place, and person;

    • Recent and remote memory; and

    • Mood and affect (e.g. depression, anxiety, agitation).

Considerations

The 1997 Documentation Guidelines often are criticized for their “specific” nature. Although this assists the auditor, it hinders the physician. The consequence is difficulty and frustration with remembering the explicit comments and number of elements associated with each level of exam. As a solution, consider documentation templates—paper or electronic—that incorporate cues and prompts for normal exam findings with adequate space for elaboration of abnormal findings.

Remember that both sets of guidelines apply to visit level selection, and physicians may utilize either set when documenting their services. Auditors will review documentation with each of the guidelines, and assign the final audited result as the highest visit level supported during the comparison. Physicians should use the set that is best for their patients, practice, and peace of mind.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

  1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, Ill.: American College of Chest Physicians; 2009:87-118.

  2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Sept. 12, 2011.

  3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Sept. 12, 2011.

  4. Highmark Medicare Services. Frequently Asked Questions: Evaluation And Management Services (Part B). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#10. Accessed Sept. 14, 2011.

  5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at: http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Sept. 15, 2011.

  6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

 

 

Determining Levels of Exam

A reviewer assigns one of four exam levels. As with the history component, documentation must meet the requirements for a particular level of exam before assigning it to any visit category (see Table 1). The requirements vary greatly between the 1995 and 1997 guidelines. The four recognized levels of history are problem-focused, expanded problem-focused, detailed, and comprehensive (see Table 2A and 2B). Similar to the history component, a few visit categories do not have associated exam levels or documentation requirements for exam elements, such as critical care and discharge day management.

As counting the number of exam elements seems rather straightforward, the most problematic feature of the 1995 guidelines involves “detailed” exam description. Overlap exists between the “detailed” and “expanded problem-focused” exam requirements. Both call for the notation of 2-7 systems/areas, but the detailed exam requires an “extended exam of the affected system/area related to the presenting problem.” Without further guidance from CMS, inconsistency flourishes. Documentation, review, and audit of the detailed exam become arbitrary.

Consider this cardiovascular exam example: “regular rate and rhythm; normal S1, S2; no jugular venous distention; no murmur, gallop or rub; peripheral pulses intact; no edema noted. Lungs clear.” Assigned credit is subject to clinical inference. Although most Medicare contractors attempt to avoid confusion and default to the 1997 requirements for a detailed exam, others attempt to define it.3 Highmark Medicare Services has uniquely developed the 4x4 tool (detailed exam=documentation of four elements examined in four body areas or four organ systems) in hopes of proper and consistent implementation of the evaluation and management (E/M) guidelines.4

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