Expert Healthcare Training on Expanded Problem Focused & Detailed Exams


Learn the difference between the two

What's considered a complete single system exam under the 1995 evaluation and management documentation guidelines . So can you combine body areas and organ systems? And it depends on where you are although the guidelines are usually interpreted pretty closely. You'll want to check with your local Medicare carrier. Some will make sure organ systems and body areas, for example, Trailblazers. Know more with this healthcare training article.

Some specifically state that this isn't acceptable and that one of the examples on that is Highmark Medicare Services, you have to use either body areas or organ systems.

So here's the big conundrum in regard to expanded problem focused exams and detailed exams. What is difference? Some payers can be two to seven body areas or organ systems with at least one being more detailed.

And we notice that with Trailblazers payer, they are using that rule of thumb. Other payers use that the expanded problem focused exam is two to four body areas. And the detailed is five to seven. And then the Highmark Medicare Services follows what they call the four by four rule.

And that would be four elements under at least four body areas or organ systems is mentioned. And then otherwise, it's up to the auditor’s discretion. Most of their auditors are nurses so they do use their skills that way in determining whether or not the exam would be of detailed nature.
What's considered a complete single system exam under the 1995 guidelines?

Interestingly enough, the evaluation and management documentation guidelines don’t stipulate exactly what this is. Most societies have come up with complete single system exams. And our expert, in one of the E M coding conferences, recommended using one of those.

However, it is self defined by the physician. And as long as the physician says, “I did a complete whatever system exam it is, I did a complete exam” and then you go into the details of that exam. Then because it is self defined, we would give you credit for that completeness of that one single organ system exam.

So again, that's an important component. What we do recommend though is to go to the colleges or to the societies to find out what they suggest to be a single system exam to fulfill this requirement.

So what would happen if we had HEENT normal, or what about abdomen small scars from prior appendectomies? No jaundice or pallor, breast exam is completely benign. Where do we put these?

Healthcare Training Tip: If you have HEENT normal, what do you do with it? Well, according to some of the payers and specifically on this count, Highmark Medicare Services says you can give credit to each of those systems. They had eyes, ears, nose and throat.

Now certainly head is a body area. So depending on the level of service, we wouldn't necessarily but counting that. Then we have eyes and then ears, nose and throat.
The best practice might be to indicate normal for each of them but they have so that they would give credit for that HEENT be normal.

Abdomen small scar from prior appendectomy. Remember, it's important for you not to just look at the category in which you have documentation but to also look at the documentation.

Because if you had one that said “Abdomen small scar from prior appendectomy”, for 1995 guidelines, it might appear as though it could go under GI but in actuality, it would be skin because we're inspecting the skin.

The element describe the skin and not the abdomen. And that's why it goes under skin and not the GI and obviously not abdomen either even though that's how it was written by the physician.

The other ones, the “No jaundice or pallor”, should this be skin or eyes? And really it depends on where you are in the exam. Usually, the physicians document a head to toe exam. And if jaundice is mentioned at the very beginning, chances are, that's going to go under eyes.

If it's further down in regard to after maybe GI or inspection of musculoskeletal inspection of skin neuro, then it might very well go under skin. You do want to look at why the patient is there and where it falls within the exam.

“Breast exam is completely benign.” Well, a breast exam is often found under skin. It could be under breast. It would not be under GU. However, to say that it's completely benign you have no idea what was done. And you won't really be able to give credit under any of these organ systems or body areas because you don’t exactly know what was done. Our healthcare training mentioned that you don’t have the details therefore you can't really make an educated assumption as to what exactly was examined.

Medical decision making and then the other service that the patient had. So in the note that was sent, in the note that was written, it says “I took an x-ray and by my read”, if you're billing for the x-ray, both the technical and the professional component can be billed. But if you did not bill for the x-ray, then you would be able to count within the medical decision making the read of the x-ray and give additional credit under medical decision making.

However, if you are billing for the x-ray, the technical and the professional components, then you wouldn't be able to count that into the medical decision making section again.

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Angela Bazigos
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Peggy J. Berry
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Duane C. Abbey
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