Key components of evaluation and management: Physical examination
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, July 1, 2018
There are three “key components” used to determine levels of Evaluation and Management (E/M) services. The first is history, which has been discussed in the two preceding Cracking the Code articles. The second is the examination and the third is medical decision making, which will be covered in next month’s article.
When trying to determine levels of examination, one is faced with determining which documentation guidelines to use: the 1995 or the 1997 version. One must adhere to one or the other version for each encounter; commingling the two is not appropriate. Although Medicare will accept either guideline (whichever provides greater advantage to the provider), insurers are more likely to use the 1997 version for claims adjudication purposes. So, let’s focus on the 1997 guidelines.
The CPT® lists four types of examinations to be used for determining levels of E/M services. These are:
-
Problem focused: A limited examination of the affected body area or organ system;
-
Expanded problem focused: A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s);
-
Detailed: An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s); and
-
Comprehensive: A general multi-system examination or complete examination of a single organ system.
The 1997 documentation guidelines base examination coding on organ systems and “bullets” of data collected from each organ system. Below is a listing of recognized organ systems:
- Constitutional
- Eyes
- Ears, nose, mouth, throat
- Neck
- Cardiovascular
- Chest (breasts)
- Respiratory
- Gastrointestinal (abdomen)
- Genitourinary (male, female)
- Lymphatic
- Musculoskeletal
- Skin
- Neurologic
- Psychiatric
- Hematologic/lymphatic/immunologic
As dermatologists, which of the above are we most likely to evaluate? The organ systems and bullet points most likely to be pertinent to various dermatologic disease evaluations are listed in the table below.
How do the above bullets relate to levels of examination? Below is a chart specifying the 1997 guidelines criteria:
During data entry and code selection one should keep in mind that the extent of the physical examination should be commensurate with the patient’s problem(s). Aggregated physical examination data not relevant to a patient’s clinical state will be rejected upon chart audit, and will not count toward determinations of visit complexity. Such audits may reveal patterns of upcoding, and could result in, at best, a request for a refund, and at worst, further audits and investigations.
Appendix C of the CPT® provides a variety of dermatology-specific patient care vignettes illustrating various levels of E/M. This can serve as a general guideline, but should be used with caution, as the diseases/conditions illustrated serve as examples of applicable levels of E/M services, but do not mean that every such patient scenario should lead to an identical level of E/M service. The E/M level of service should be individualized to the medically necessary degree of service appropriate to the patient’s clinical presentation.
Example 1: You do a complete skin examination of a patient with a past history of malignant melanoma, palpate lymph node basins in the neck, axillae, and groin, examine the eyelids and conjunctivae as well as the lips, gums, oral mucosa, and tongue. How many examination bullet points have you accumulated?
Answer: 14. Based upon the above scenario, 14 bullet points were accumulated from 4 organ systems: skin (10), lymphatic (1), eyes (1), ears-nose-mouth-throat (2). This reaches a Detailed’ level of examination.
Example 2: You do the above examination and document a “complete skin examination” as your description of the skin examination. This charting validates the accumulation of 10 skin bullet points.
Answer: Incorrect. Each of the examined skin areas characterized by a bullet point are best listed individually in the patient record. This validates their examination. “Complete skin examination” or “full skin check” may seem to characterize what was done, but upon chart audit is likely to be rejected as inadequate documentation or counted as one system.
Example 3: The following appears in a patient record: Well-developed, well-nourished male appearing comfortable and in no distress, oriented, and conversational. Complete skin examination done including the head, neck, chest, abdomen, genitalia, buttocks, back, all four extremities, nails and nail beds, lips, tongue, gums and oral mucosa, eyelids, and conjunctivae. An 8 by 6 mm asymmetrically bordered, brown to black, irregularly pigmented macule is present on the left mid back. Palpation of neck, axillary and groin lymph node basins reveals no palpable nodes. Which type of examination is reached in the above scenario?
Answer: Detailed. The 6 documented organ systems are: Constitutional, Psychiatric, Skin, Musculoskeletal, Ear-nose-mouth-throat, Eyes. From these there were 16 extractable bullet points.
