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Examination

  1. Medicare coverage pelvic screening (G0101) requires performance of seven of the 11 examination elements. Does noting the surgically absent organs count towards the seven elements since those areas are examined but noted absent?

    Answer:
    Yes, notation of surgically absent organs may be counted toward examination of the required elements for G0101. Updated 8/29/2017

  2. Please clarify what documentation of “HEENT normal” would represent in terms of organ systems and/or body areas.

    Answer: HEENT represents head, eyes, ears, nose and throat.

    1. Head and Neck: two body areas
    2. Eyes and Ears/Nose/Throat: two organ systems Updated 8/29/2017

  3. Please clarify coding for an examination in which an essential element(s) must be omitted due to the patient’s clinical condition during the examination. Will 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. Updated 8/29/2017

  4. Since NGS is allowing providers to continue use the original detailed exam, how does NGS define “expanded documentation”?

    Answer:
    Expanded documentation at the detailed level entails specific findings relative to organ systems or body areas in which the patient is exhibiting clinical symptoms. Updated 8/29/2017

  5. 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 is justified. Updated 8/29/2017

  6. Under 1995 examination guidelines, is it still permissible to combine body areas and organ systems towards the Expanded Problem Focused and Detailed exam levels?

    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. Updated 6/9/2017
     
  7. What body area or organ system is applicable for documentation of “no JVD” in an examination?

    Answer:
    “No JVD” (meaning no jugular venous distention) could receive credit under body area (neck) or organ system (cardiovascular). Updated 6/9/2017
     
  8. In the constitutional portion of a physical exam, is BMI counted as a vital sign?

    Answer:
    BMI calculation requires measurement of height and weight and cannot count as an additional vital sign when height and weight are measured and documented.

    When height and weight are not identified, documented BMI can be counted as a vital sign, since there is a presumption that height and weight have been calculated to achieve the BMI. Updated 6/9/2017
     
  9. Will bilateral examinations 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. Updated 6/9/2017
     
  10. 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. Updated 9/19/2017
     
  11. 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. Updated 6/9/2017
     
  12. Can an exam bullet be counted to base an E/M code level of service if the patient refused to allow the provider to perform that portion of the exam? For example can the bullet for gait/station be counted if the provider intended to evaluate gait/station but the patient refused this element of examination?

    Answer:
    In counting performed bullets for a visit, the provider may only count those actually performed and documented. Updated 6/9/2017
     
  13. For an expanded problem focused and detailed exam can you combine body areas and organ systems?

    Answer:
    Yes, body areas and organ systems can be combined for these levels of coding. Updated 6/9/2017
     
  14. Does a complete examination of a single organ system meet the requirement for a comprehensive level of examination?

    Answer:
    A complete examination of a single organ system is acceptable for a comprehensive examination, as per the CMS 1995 guidelines. Updated 6/9/2017
     
  15. When cardiovascular and pulmonary (organ systems) are routinely included as standard protocol for the physical exam for all patients (as would be appropriate for good patient care), should they be counted toward the level of exam for presenting problems not related to those organs systems, e.g., conjunctivitis, UTI, knee pain?

    Answer: The medically necessary scope of examination is determined by the presenting problem. The problems identified here (conjunctivitis, UTI, knee pain) would not warrant a cardiovascular or pulmonary examination as medically necessary. An exception to this rule may occur when the examiner observes signs or symptoms of cardiac or respiratory problems during a focused examination of the body area relative to the patient’s complaint(s). Updated 6/9/2017
     
  16. Would the documentation of “no rebound” count as abdomen or GI system?

    Answer:
    “No rebound” refers to an abdominal examination. Updated 6/9/2017
     
  17. To which organ system or body area would the comment “no clubbing, cyanosis or edema” be counted?

    Answer: This comment would apply to “extremity” as a body area and to the cardiovascular organ system. Updated 6/9/2017
     
  18. In completing and documenting a comprehensive examination, would examination of the abdomen and lungs be sufficient?

    Answer:
    A comprehensive examination requires eight organ systems. The term “abdomen” may be used to represent the GI system and “lungs” to represent the respiratory system as long as the examination reflects organ function. An example: Lungs: “abnormal breath sounds in bilateral lower lobes”; “Abdomen (when used to represent the GI system): soft, nontender, active bowel sounds.” Of note, documentation of an additional six organ systems would be necessary in order to reach the comprehensive level of coding. Updated 7/31/2019
     
  19. When a patient returns for a follow-up visit, for a complaint previously and successfully treated, is that subsequent visit considered to be medically necessary?

    Answer:
    follow-up visit may be considered medically necessary, when the provider plans to evaluate effectiveness of prior treatment. The fact that the patient no longer has a complaint does not negate the medical necessity of the visit. Two differing examples:
    • A patient previously seen for headaches and found to be hypertensive, with medication prescribed, now returns symptom-free for blood pressure evaluation. This visit would be medically necessary to evaluate the patient’s response to medication.
    • A patient previously seen for a common cold now returns for a follow-up visit with no complaints. Since the original visit was for a self-limiting condition and no medical treatment was initiated, the medical necessity for a follow-up visit is questionable and should be carefully considered. Updated 6/9/2017

  20. If there is documentation of 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. Updated 6/9/2017
     
  21. 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. Updated 6/9/2017
     
  22. Can an examination of seven organ systems and/or body areas documented by a checklist count as a detailed exam?

    Answer:
    NGS discourages the use of a checklist format for detailed exams, unless the examiner expands upon positive findings with specific facts and observations. Updated 6/9/2017
     
  23. How many specific findings must be documented for a complete exam of a single organ system?   

    Answer:
    The 1997 Documentation Guidelines for Evaluation and Management Services (595 KB) are available on our website. Expectations vary by specific organ system; a comprehensive examination would include documentation of all bullets listed for the selected organ system. Updated 6/9/2017
     
  24. What is required for a comprehensive physical exam using the 1995 E/M guidelines? Do you have to have eight or more organ systems or can you use the body areas?

    Answer:
    When documenting a comprehensive physical examination, based on 1995 Documentation Guidelines for Evaluation and Management Services, examination of eight organ systems is the required standard. Updated 6/9/2017
     
  25. When using the 1995 guidelines for the physical exam, is the use of the word “unremarkable” permissible, if an organ system has normal findings?

    Answer:
    Yes, the word “unremarkable” is acceptable as an indication that the organ system examination revealed no abnormal clinical findings. Updated 6/9/2017
     
  26. Our question is specific to counting the extremity body areas and organ systems. For example, a cardiologist performs an examination which is comprised of both organ systems and body areas, listening to the heart, examining the neck, abdomen and extremities for edema. Can each element be counted as either a system or area as long as the same element is not counted as both a system and an area?

    Answer:
    Yes, both organ systems and body areas are included in counted in assessing the documented level of examination and should not overlap for that purpose. Updated 6/9/2017

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