Documenting the Patient Examination

 In Articles, Coding & Documentation

It seems simple enough to document the negatives and pertinent positives of patient examinations, right? If you document what you do, how do you know if it meets the guidelines for the level selected? What if the patient is complex? What is required for a comprehensive exam?

CMS provides two options for documenting the examination. Providers can use either the 1995 guidelines or the 1997 guidelines but not a combination of the two. The following summarizes the rules for each:

1995 Guidelines

The levels of E/M services are based on four types of examination:

  • 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);
  • Comprehensive – A general multisystem exam to include at least eight body areas or systems.

For purposes of examination, the following body areas are recognized:

  • Head (including the face)
  • Neck
  • Chest (including breasts and axillae)
  • Abdomen
  • Genitalia (groin, buttocks)
  • Back (including spine)
  • Each extremity

For purposes of examination, the following organ systems are recognized:

  • Constitutional (e.g., vital signs, general appearance)
  • Eyes, Ears, nose, mouth, and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic

The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.

1997 Guidelines

The 1997 documentation guidelines are based on documenting specific bullets. The total number of bullets then translates to the examination level, as further described in the Content and Documentation Requirements below.

The 1997 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit: general multi-system examination and single organ examination. These types of examinations have been defined for general multi-system and the following single organ systems:

  • Constitutional (e.g., vital signs, general appearance)
  • Eyes
  • Ears, nose, mouth, and throat
  • Cardiovascular
  • Respiratory
  • Genitourinary (female)
  • Genitourinary (male)
  • Musculoskeletal
  • Skin
  • Neurological
  • Psychiatric
  • Hematologic/lymphatic/immunologic

A general multi-system examination or a single organ system examination may be performed by any physician, regardless of specialty. The type of exam and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).

A reproduction of the general multi-system examination follows:

General Multi-System Examination

3Q chart 1

3Q chart 2

3Q chart 3

3Q chart 4

 

 

Content and Documentation Requirements

3Q chart 5 

For the single organ system examination components you may reference page 58 of this link.

Some important points to remember when documenting general multi-system and single organ system examinations in both the 1995 and the 1997 documentation guidelines are:

  • Specific abnormal and relevant negative findings during the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is insufficient.
  • Abnormal or unexpected findings during the examination of any asymptomatic body area(s) or organ system(s) should be described.
  • 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).

MSOC Health primarily utilizes the 1995 documentation guidelines in reviewing notes and provider education. In most cases, the 1995 guidelines are more beneficial to the provider to further support the complexity of the encounter. However, many EMR templates use the 1997 guidelines. Since the 1997 guidelines are built on counting bullets it is easier for the EMR to determine the level. Regardless of which documentation guidelines the practice uses, it is important to understand the examination documentation methodology to prevent a perceived cloning of notes. The next issue of MSOC Health’s E-Newsletter will address cloned notes in greater detail.

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