E&M Exam

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Question:

I attended a recent ASPS coding course and heard you speak – you were terrific! i didn’t realize how important E&M coding was and more importantly the documentation for it. When consider level 4 and 5 new patient or outpatient consults, I see that a comprehensive physical exam is needed. Should I be using the 1995 or 1997 guidelines?

Answer:

Thank you so much – I love what I do and I hope it shows when I teach. Yes, E&M coding and documentation is very important. You’ve asked a good question and one that is not easily answered by me – only you can decide which exam guidelines to use based on the examination you perform.

A comprehensive examination is required for a level for level 4 and 5 new patient visits (99204, 99205) and outpatient consultations (99244, 99245). So what is a comprehensive exam?

Medicare’s 1995 guidelines are organ system-oriented; a comprehensive exam requires assessment and documentation of at least 8 of the following 12 organ systems:

  1. Constitutional (e.g., vital signs, general appearance)
  2. Eyes
  3. Ears, nose, mouth and throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Skin
  10. Neurologic
  11. Psychiatric
  12. Hematologic/ lymphatic/immunologic

Medicare’s 1997 guidelines are organ system-specific, meaning each organ system includes specified examination elements (also known as “bullets” or “elements”). The following organ systems have a specified exam:

  1. Cardiovascular
  2. Ears, Nose, Mouth and Throat
  3. Eyes
  4. Genitourinary (Female)
  5. Genitourinary (Male)
  6. Hematologic/ Lymphatic/Immunologic
  7. Musculoskeletal
  8. Neurological
  9. Psychiatric
  10. Respiratory
  11. Skin

Alternatively, Medicare’s 1997 guidelines allow for a general multi-system exam. You’ll need to review each organ system’s 1997 exam elements as well as the general multi-system exam elements to determine if this works best for you.

I recommend you look at the CMS website for more detailed information about the examination guidelines.

Most plastic surgeons find that it is difficult to report level 4 and 5 consultation (9924x)/new patient codes (9920x) due to the comprehensive examination requirements. However, oftentimes these high level codes can be reported based on your face-to-face time spent counseling the patient in the office setting.

I’d be happy to review a couple of your E&M notes and work with you to determine which exam guidelines are to your benefit and whether your documentation meets the criteria for level 4 and 5 codes. Please contact Natalie Loops at KZA for more information about KZA’s professional fees (312.642.5616 or info@karenzupko.com).