by Grant Huang, CPC, CPMA
April 29th, 2016
You might think the physical exam portion of an E/M note is one of the simplest areas to audit. After all, you don't have to worry about all the possible words a physician might use in the history that you'll need to qualify as elements of the history of present illness (HPI).
But the exam can be tough, especially when it comes to figuring out whether a detailed level exam is supported. For the purposes of this article, we'll focus on the 1995 E/M guidelines. Let's first review the four levels of exam.
Problem-focused (PF). One body area or system related to the problem.
Expanded problem focused (EPF). 2-7 systems, limited exam.
Detailed (DET). 2-7 systems, extended exam.
Comprehensive (COMP). Eight or more systems, not body parts.
Body areas vs. organ systems
It's important to note that body areas are not organ systems. You may see a note specifying "neck" as an exam component, and that the neck is "supple, non-tender, no lymphadenopathy." The neck is a body area, so for a comprehensive exam, it doesn't count. However, "no lymphadenopathy" can be credited for a lymphatic system exam, so you get a system out of what seems to be a body area exam.
This is where most of the complexity lies. Under the 1995 guidelines, all the other levels of exam are clear, especially the comprehensive level. While a comprehensive exam requires more documentation, at least the guidelines are explicit. For a detailed exam, you need 2-7 systems examined in an "extended" fashion. If the note doesn't have a system with an "extended" exam, the overall level of exam falls back down to expanded problem focused.
Limited vs. extended exam of a system
The bottom line is that there's no single consensus answer to the question of what makes an exam with seven systems "extended" vs. only "limited". You should absolutely check your payer or Medicare carrier's website for any specific definition they may have. Some payers have accepted 2-4 systems as limited, and thus appropriate for expanded problem focused exam, and 5- 7 systems as extended, and supporting a detailed level of exam. If there is any consensus, it's that for a system to be documented in an extended fashion, it must contain more than just a single term or phrase such as "within normal limits." It should go into more detail, either listing additional information if normal, or more descriptions of abnormalities. Many auditors consider the exam detailed if 2-7 systems are captured, and at least one system contains three or more bullet points or descriptive elements.
Abdomen: soft, tender, no masses. Diffuse discomfort that worsens with movement. Active bowel sounds. Negative distention. No flank pain. No hepatosplenomegaly.
If you had 2-7 systems examined and "abdomen" is listed as above, you have an extended gastrointestinal exam and an overall detailed exam. Remember, even through "abdomen" is a body part, you can clearly extract a GI organ system exam component.
4x4 method for detailed exam
One Medicare carrier, Novitas, uses the so-called "4x" method, which means a detailed exam requires at least 4 bullets from 4 different organ systems or body areas for a total of 16 bullets. This is potentially more documentation than a comprehensive exam under 1995 guidelines. However, Novitas at least makes it absolutely clear what is required for a detailed exam. If you are auditing a provider under Novitas jurisdiction (AR, CO, DC, DE, LA, MD, MS, NJ, OK, PA, TX), you'll need to follow the 4x4 rules for a detailed exam for Medicare cases.
Your first move should be to check your local coverage determinations (LCDs) on E/M services and what constitutes a detailed exam. If there are no specific LCDs, follow the rule above that defines a limited exam as 2-7 systems, briefly documented with less than 3 elements per system, and a detailed exam as 2-7 systems, with at least one system documented in an extended manner with 3 or more elements and greater descriptive detail. You can also switch to the 1997 guidelines for a detailed exam, which requires 12 bullets for a single system or body area.