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The information below is based on CMS 1995 and 1997 E/M guidelines for both inpatient and outpatient services during calendar year 2020 and prior.

CMS issued a new set of standards for outpatient and office services in the code range of CPT 99202-99215 on 1/1/2021. Refer to Examination On or After 1/1/2021 for related information.

Examination Prior to 12/31/2020

  1. Please clarify coding for an examination in which an essential element(s) must be omitted due to the patient’s clinical condition. Does the phrase "exam deferred" count toward that element? Example: ED stroke patient, for whom the neurologist cannot assess the patient’s gait and station due to temporary paralysis.

    Answer:
    When a required element(s) of examination cannot be achieved due to the patient’s current clinical condition, this should be documented in the medical record. A comprehensive examination may be performed without this element(s), but this requires careful documentation as to the reason for the absent information. Revised 1/20/2021

  2. During a visit for a chronic condition, a physician performs a history and examination at a higher level that appears to be medically necessary, and this reveals a previously unidentified condition.  Should the newly discovered condition be counted toward the level of  E/M coding for the visit?

    Answer:
    Despite the absence of patient complaint(s), a physician’s clinical observation may support the need for a more extensive examination than supported by the chronic condition. In these circumstances, the medical necessity of the higher level examination must be documented and may be justified. Revised 1/20/2021

  3. May 1995 E/M body areas and organ systems be combined in assessing the level of coding for an examination?

    Answer:
    As per 1995 CMS E/M guidelines, examination of body areas and organ systems can be combined in assessing the level of coding detail.

    As a reminder, 1995 and 1997 guidelines cannot be combined in scoring an individual E/M service. Revised 1/20/2021
     
  4. Does a bilateral examination count as two body areas if the findings on each side are documented?

    Answer:
    One point is allotted per body area or organ system when bilateral examination is performed. Revised 1/20/2021 
     
  5. Would documentation of “vital signs stable” be sufficient for a problem focused exam under 1995 or 1997 guidelines?

    Answer:
    Vital signs is listed as an “organ system” in the CMS 1997 E/M guidelines, and must include documentation of three vital signs. These usually include temperature, height, weight and blood pressure. These values are commonly obtained by clinical office staff, so documentation of these vital signs does not in itself support an examination by the performing/billing provider. The term “vital signs stable” would not support a problem focused exam either, since it is not specific to what the vital sign readings were found to be. Unless the patient’s problem was specifically relevant to one of those vital signs (e.g., hypertension or morbid obesity), the documentation of vital signs alone would not necessarily support the examination as clinically relevant to the presenting complaint. Reviewed 1/20/2021
     
  6. Is a physical exam required documentation for billing a discharge E/M service (CPT codes 99238/99239)?

    Answer:
    A physical examination is not a required component of an E/M discharge service (CPTs 99238‒99239), unless indicated by the patient’s clinical status on the date of discharge. The note must reflect a discussion of the hospital stay and plans for post-discharge care, preparation of records and prescriptions and referral forms as necessary. Reviewed 1/20/2021 

  7. When documentation describes an examination of multiple body areas or systems that are unrelated to the presenting problem, does NGS give credit on an audit to the examination of the unrelated systems? Example, if a client presents with an earache and the provider documents an examination of nine or more systems or body areas (e.g., includes abdomen, GU, GI, neuro, psych, back), does NGS give credit for a comprehensive exam?

    Answer:
    Medical necessity is the driving factor for all Medicare services. NGS expects that E/M services are performed to the degree supported by the presenting problem. The need for a comprehensive examination based on a complaint of earache would be highly unusual. In that unusual scenario, the examiner might, through an overall assessment, determine that the patient is unusually pale (perhaps severely anemic), or perhaps notice a highly suspicious lesion on the patient’s neck, while examining the ear. Those observations might warrant a more comprehensive examination, but in the simple scenario of a straightforward earache, the medical necessity of a comprehensive examination would not be supported by the clinical problem. Revised 1/20/2021
     
  8. How is an organ system exam distinguished from a body area exam?

    Answer:
    Body areas are anatomically defined by specific body locations, whereas organ systems may physiologically impact multiple body areas. Reviewed 1/20/2021
     
  9. Can an examination of seven organ systems and/or body areas documented by a checklist count as a detailed exam?

    Answer:
    This may be permissible if the examiner expands upon positive findings with specific facts and observations. Revised 1/20/2021

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Examination Prior to 12/31/2020
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