Coding an evaluation and management (E/M) service is very subjective. This article is intended to provide you with the method Novitas uses to score a detailed exam.
Our clinical reviewers use the 1995 E/M Guidelines and 1997 E/M Guidelines provided by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association to make a determination on whether an examination is expanded problem focused or detailed. We use the guidelines that is most beneficial to the clinician in determining the level of service.
Under the 1995 E/M Guidelines, both the expanded problem focused exam and the detailed exam provide for up to 7 systems or 7 body areas. This has led to variability in reviews using the 1995 guidelines, and requiring an interpretation for proper and consistent implementation of E/M guidelines. However, the key to the difference between the two is the amount of detail documented in each organ system or body area.
The 1997 E/M Guidelines provide a more specific guide for determining the difference between an expanded problem focused exam and a detailed exam using bullets. The bullet system is not used when scoring based on the 1995 guidelines.
Our nurse reviewers and physicians have a clinically derived method called 4 x 4, to assist in implementing the E/M guidelines and decreasing the area of ambiguity.
The 4 x 4 method applies to the exam only and is a way to ensure you have 4 exam items in 4 body areas or 4 exam items in 4 organ systems; thus, reducing reviewer variability. This method is consistent with the way medicine is practiced as confirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to Physical Examination by Barbara Bates, M.D.
When reviewing a medical record and scoring the exam, our medical staff will automatically score a detailed exam if 4 or more exam items are noted in the medical record for 4 or more body areas or organ systems. However, less than such can still be a detailed exam based on the reviewer's clinical judgment, which is considered clinical inference.
Our nurse reviewers also use their clinical knowledge while reviewing medical record documentation to determine the correct and appropriate level of care. It provides for an individual consideration, and makes the review of all services (including E/M examinations) fairer to the physician.
Note: Clinical inference overrides the 4 x 4 method; and is in keeping with CMS instructions for reviewing all medical records.
Again, our reviewers utilize the 1995 or 1997 guidelines when reviewing E/M services, and guidelines that benefit the provider.
If one of the specialty exam score sheets in the 1997 E/M guidelines would benefit the physician more in the audit process, those score sheets will be used for the examination portion of the record instead of the 4 x 4 method.