CMS has published two separate Documentation Guidelines for Evaluation and Management (E&M) Services: one in 1995, the other in 1997. For any patient encounter, either may be used but not a combination of the two. An understanding of these two guidelines allows a physician to make an informed choice between them, selecting the one most suitable to his clinical practices and preferences.
The only significant difference between 1995 and 1997 is their requirements for physical examination. Both versions identify 12 organ systems (OS) and 7 body areas (BA) that may be used for documentation of a physical examination (see Table 1), and E&M recognizes 4 levels of physical examination as defined by the guidelines: comprehensive, detailed, expanded problem focused (EPF) and problem focused (see Table 2).
However, the 1997 guideline has specific content requirements that must be included, while the 1995 guideline does not require specific content for the areas examined, leaving this to the physician's discretion. For example, the 1997 guideline for the neurologic exam requires examination of cranial nerves, deep tendon reflexes and sensation. The 1997 guideline specifies at least 2 elements in each of 9 BA or OS. Under the 1997 guideline, if any of the required content is omitted, the exam may be discounted as incomplete. Also, in contrast to 1995, a statement of “negative” or “normal” is not acceptable documentation. On the other hand, 1997 allows use of a documentation “checklist” (perhaps prompted by an electronic medical record template) that is essentially impervious to challenge.
Because the 1995 guideline does not identify the specific documentation expected for areas examined, it might be subject to audit challenges. Some other important observations regarding the 1995 definitions include:
- A “general multi-system” (comprehensive) exam should include findings for 8 or more of the 12 OS, perhaps excluding BAs. Focusing on the 12 OS would be prudent.
- There are no definitions of “extended” and “limited” that distinguish the detailed and EPF exams. A general rule of thumb is 2 to 4 BA/OS for the EPF and 5 to 7 BA/OS for the detailed exam.
- No specific documentation content is required for any type of physical exam, just the number of BA/OS examined, containing any pertinent content at the physician's discretion.
- Specific abnormal and relevant negative findings of affected or symptomatic body area(s) or organ system(s) should be documented and described. A notation of “abnormal” without further description is insufficient.
- A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).
Physical exam may determine payment
The type of physical exam performed is one of the 3 key components defining the E&M level of service that can be billed and therefore the reimbursement for services rendered (see Table 3). If the physical exam is not documented as required by the guidelines (either 1995 or 1997), the appropriate level of service intended cannot be billed and will be downgraded to the level for the type of exam reflected by the documentation.
For example, if a high-level admission history and physical (99223) was intended with a comprehensive history and high-complexity decision making but examination of only 7 organ systems is documented, code 99221 (lowest E&M level) must be billed. Another example would be failure to document any physical exam at all on a subsequent visit, in which case a claim for payment cannot even be submitted.
The greatest opportunity for improving E&M code assignment is the documentation of the comprehensive physical exam required for the initial patient encounter (admission H&P) by both high and moderate E&M levels of service. If a comprehensive exam is not documented, only the lowest level E&M code can be assigned. As previously mentioned, the 1995 guideline requires documentation of findings in 8 or more of the 12 organ systems and the 1997 version specifies at least 2 elements in each of 9 BA or OS.
Documentation of subsequent visits is not nearly so challenging, and either 1995 or 1997 seems simple. A “detailed” exam will qualify for the highest E&M level (code 99233 or 99226):
- under the 1995 guideline, with 5 to 7 BA/OS with any pertinent content at the physician's discretion.
- under the 1997 guideline, with at least 12 elements in 2 or more BA/OS or at least 2 elements from each of 6 BA/OS.
In conclusion, physical examination requirements of both the 1995 and 1997 guidelines are quite comparable, except for the comprehensive examination, which is needed for all but the lowest level of initial patient encounter (admission H&P), whether inpatient or observation.
The 1995 guideline is more lenient but not impervious to challenge. The 1997 guidelines have strict documentation content requirements that should not be subject to audit challenge, but if any required element is omitted, the exam may be considered incomplete. The choice is yours, so choose wisely.