Exam Jen Godreau, BA, CPC, CPEDC

Director of Development & Operations

Supercoder.com

jenniferg@supercoder.com

January 2012

Agenda 1. Embrace the GRAY!

2. Put your clinical savvy to the TEST

3. Make your doctor’s documentation work for them

4. Increase your vocabulary savvy

4 Types of Examination Problem focused

Expanded problem focused

Detailed

Comprehensive

Terms and Their Systems

Problem Focused Exam Require:

1 body area or

1-5 bulleted elements

New patient visits, consults, ED services, and long-term care requires that you meet the criteria of all 3 key components:

99201, 99241, 99251

99281

99324

Problem Focused Exam Services that require performing and documenting 2

of the 3 medically necessary key components listed with the first levels of an established patient office visit are:

a PF exam (99212)

subsequent hospital care (99231)

subsequent nursing facility ( 99307)

long-term care (99334).

Problem Focused Exam In a 99212, the physician is examining that body

area/system only.

Example: a follow-up ear exam in which the OM is resolved involves the physician examining the ear only.

Expanded Problem Focused An expanded problem focused incorporates many

body areas or systems

a limited examination of the affected body area or system plus 1-6 systematic or related systems

Only give credit for performed and documented medical physician examination findings that were done based on the encounter’s medical necessity

Example: Our patient with OM on initial presentation has a fever,

runny nose, and stomach ache. The physician examines those systems and documents his findings.

In addition to examining the ear (1 body system), you have stomach under body system GI. Although the physician also examined the patient’s nose, you still have 2 systems. Ear, nose, mouth, and throat all qualify as 1 system.

If the patient also had goop coming out of R eye, the eye exam counts as an additional system.

The 1 Count Rule ENMT: 1 system credit

no matter the structures involved.

Test it Wt 186 lbs

Ht 66 in

BP: 120/80

PR: unfound

Temp: 99.0

POx: 99%

Dress in disarray.

The answer is 1! Even though you have 7 pieces of constitutional information – you get credit for a system once only.

How many systems?

Test It You have murmur documentation that indicates a

cardiovascular (CV) exam and the abbreviation “c/c/e.”

Is this notation, plus CV, enough body areas/systems for an expanded problem-focused exam?

Yes, c/c/e stands for cyanosis, clubbing, edema

Expanded Problem Focused Physical Exam

On 3/3 services, expanded PF is required for both new patient office visit code 99202, consult codes 99242 and 99252, ED codes 99282 and 99283, and on long-term care code 99325.

On 2/3 services, EPF is listed as a component of 99213, 99232, 99308 for NF, and 99385 for LTC.

Detailed exam The 1995 E/M Documentation Guidelines distinguish

between an expanded problem focused examination and a detailed exam as both requiring at least two body areas and/or systems and that one is a ‘limited exam’ and the other is ‘extended’.

Tip: For areas that your physician regularly examines, be familiar with his usual detail. That way, when you see more detail, you can distinguish an expanded problem focused exam from a detailed one.

Keywords For respiration: Documentation will have the respiratory

rate, assessment of respiratory effort, auscultation findings and usually a re-evaluation of the respiratory system and usually a reevaluation of the respiratory system.

For abdomen examination: Documentation would have how the abdomen looks in general, palpation of liver, spleen, masses, area of pain, degree of pain, bowel sounds, etc.

Hint: If you’re taking the E/M or AAPC’s primary care specialty exams, know the difference between limited and detailed documentation.

Detailed exam A detailed exam goes to 3/3 key components for a

99203, 99243, 99253, 99284, the lowest level of observation care (99218 and 99234) and NF care (99304), as well as midlevel long-term care 99326.

In the 2/3 category, detailed exam is listed in 99214, 99233, 99309, 99336.

1997 guidelines require:

12-17 bulleted elements

from 2 or more systems for a detailed exam.

99213 1995 guidelines: 99213 is an expanded problem focused

exam of 2-6 brief systems.

Example: Documentation includes:

General: alert and responsive

Ears: left clear, right fluid

Nose: clear drainage

Chest: clear

CV: No murmur

This counts as 4 systems examined for 99213

99214 Example General: Crying on Mom’s lap with flaring nostrils ENT: clear runny nose, ears clear Resp: Resp. rate 30 , substernal retractions, in obvious

distress. Rales and rhonchi bilaterally. Will do neb and reevaluate.

Heart: Heart Rate rapid but normal Re-eval: Improved but still having wheezing. Resp rate 20

will repeat neb Re-eval: Much improved, no further wheezing. Resp rate

normal. 1 system in detail – respiration, plus 3 systems that are

brief: Constitutional, ENT, and Cardiovascular.

Comprehensive Physical Exam Requires a general multi-system exam of 8 or more

systems or complete exam of a single organ system.

For the complete exam requirements, see the 1997 EM guidelines individual single system exam requirements at:

http://www.supercoder.com/category/cms/evaluation-management/

Exam Requirements Type of Physical Examination Body System/Area(s) required

Problem focused 1 system or area (1-5 bulleted elements)

Expanded problem focused 2-7 brief systems or areas (6-11 bulleted elements)

Detailed 1 system or area in greater detail and 1-6 additional BRIEF

system(s)

(12-17 bulleted elements in 2 organ systems)

Comprehensive 8+ systems OR complete single system exam

(18 or more bulleted elements from 9 or more systems

Complete single system, see individual single system exam requirements.)

1995 or 1997? Tip: If your practice or group uses the `95 guidelines,

keep a copy of the `97 ones.

Example: doctor documents “edema” and “c/c/e”, but not murmur. You could count edema for the CV, and clubbing and cyanosis could go to musculoskeletal.

The 1997 guidelines show: Musculoskeletal: Inspection and/or palpation of digits

and nails (e.g.,clubbing, cyanosis, inflammatory conditions, petechiae,ischemia, infection, nodes)

Cardiovascular: Examination of extremities of edema and/or varicosities

Improve Your Vocab AAO: Awake, Alert and Oriented AAPC: EM certification audit sheet from Stephanie Jones's E-M for Coding

Class Part (Stephanie Jones, CPC, CEMC) c/c/e: Cyanosis, Clubbing, Edema CTA: Clear To Auscultation DTR: Deep tendon reflex Edema: Edema is swelling caused by excess fluid trapped in your body's tissues.

Although edema can affect any part of your body, it's most commonly noticed in your hands, arms, feet, ankles and legs.

EOMI: Extraocular Movements Intact NAD: no abnormalities detected PERRL: Pupils equal, round & reactive to light & accommodation ROM: Range of Motion RRR: Regular Rate and Rhythm/ Respiration, Rate, and Rhythm WDWN: Well Developed Well Nourished WNL: Within Normal Limits

Thank

YOU!

Helping coders,

help physicians!

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