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Evaluation & Management
Examination Component:
Documentation of Complexity
OH/WV/SC
December 2, 2009
Disclaimers
This presentation was current at the time it was published or uploaded onto the
Palmetto GBA Web site. Medicare policy changes frequently so links to the source
documents have been provided within the document for your reference.
This presentation was prepared as a tool to assist providers and is not intended to
grant rights or impose obligations. Although every reasonable effort has been made
to assure the accuracy of the information within these pages, the ultimate
responsibility for the correct submission of claims and response to any remittance
advice lies with the provider of services.
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff
make no representation, warranty, or guarantee that this compilation of Medicare
information is error-free and will bear no responsibility or liability for the results or
consequences of the use of this guide.
This publication is a general summary that explains certain aspects of the Medicare
Program, but is not a legal document. The official Medicare Program provisions are
contained in the relevant laws, regulations, and rulings.
Palmetto GBA December 2009
2
Objectives
•
Provide an overview of the Comprehensive Error Rate Testing
Program (CERT)
•
Identify general documentation principles
•
Review the examination component of an Evaluation &
Management (E/M) service
•
Discuss documentation tips for the examination component
•
Identify resources for CERT and E/M services
Palmetto GBA December 2009
3
Comprehensive Error Rate Testing (CERT) Program
The Comprehensive Error Rate Testing Program • The Comprehensive Error Rate Testing (CERT)
program monitors and reports the accuracy of
Medicare claims
– Paid Claims Error Rate: dollars
– Provider Compliance Error Rate: accuracy
• Most recent data: May 2008 CERT report
• CMS views these error rates as a measure of
how well contractors communicate Medicare
guidelines to providers and staff
Palmetto GBA December 2009
5
CERT Paid Claims Error Rates for Palmetto GBA May 2008 Report: 5 Highest Code Groups
Ohio and West Virginia
25.0%
22.0%
19.2%
20.0%
= All three of the three key
components required
15.0%
11.0%
10.7%
10.0%
7.3%
5.0%
0.0%
Hospital visits - initial
Consultations
Office visits- new
Palmetto GBA December 2009
Hospital visitssubsequent
Chiropractic services
6
CERT Paid Claims Error Rates for Palmetto GBA May 2008 Report: 5 Highest Code Groups
South Carolina Part B
30.0%
25.0%
= All three of the three key
components required
24.2%
19.6%
20.0%
15.0%
12.1%
11.6%
9.3%
10.0%
5.0%
0.0%
Chiropractic services
Consultations
Hospital visitssubsequent
Palmetto GBA December 2009
Office visits- new
Other tests
7
Reasons for Errors
• Most errors resulted from documentation
supporting a lower level of service than
the submitted code
• A few consultations were changed to
“visits” (3 R’s)
• “3 of 3 key components” – required for
initial hospital visits, consultations, and
new patient office visits
Palmetto GBA December 2009
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General Documentation Principles
General: Principles of Medical
Record Documentation
•
•
•
•
•
•
•
The medical record should be complete and legible
Each patient encounter should include:
– Reason for encounter and relevant history, physical examination
findings, and prior diagnostic test results
– Assessment, clinical impression, or diagnosis,
– Plan for care
– Date and legible identity of the observer
If not documented, the rationale for ordering diagnostic and other ancillary
services should be easily inferred
Past and present diagnoses should be accessible to the treating and/or
consulting physician
Appropriate health risk factors should be identified
The patient’s progress, response to and changes in treatment, and revision
of diagnosis should be documented
The CPT and ICD-9-CM codes reported on the health insurance claim form
or billing statement should be supported by the documentation in the
medical record
Palmetto GBA December 2009
10
Examination Component
COMPONENTS OF E/M SERVICES
CHIEF COMPLAINT
1.
2.
3.
HISTORY COMPONENTS
–
–
–
HISTORY OF PRESENT ILLNESS (HPI)
REVIEW OF SYSTEMS (ROS)
PAST, FAMILY, SOCIAL HISTORY
(PFSH)
PHYSICAL EXAMINATION
DECISION MAKING
–
–
–
DX/MGT OPTIONS
TYPE OF DATA
RISK ASSESSMENT
= SELECTION OF CPT CODE
Palmetto GBA December 2009
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TYPE (COMPLEXITY) OF EXAMINATION
CUMULATIVE: MORE DATA MORE COMPLEXITY
1995
BODY
AREAS
AFFECTED
AREA
1995
AFFECTED
SYSTEMS SYSTEM
AFFECTED AREA +
UP TO 6 OTHERS
2-7 AREAS,
MORE DETAIL
8+ AREAS
AFFECTED SYSTEM
+ UP TO 6 OTHERS
2-7 AREAS,
MORE DETAIL
8+ SYSTEMS OR
COMPLETE
SINGLE SYSTEM
EXAM
1997
GUIDELINES
6-11 BULLETS IN
1- 5
BULLETS IN 1+
SYSTEMS/AREAS
1+
SYSTEMS
/AREAS
12+ BULLETS IN
2+
SYSTEMS/AREAS
2 + BULLETS FOR
EACH OF 9 +
SYSTEMS/ AREAS
EXAM
TYPE
PROBLEM
FOCUSED
DETAILED
COMPREHENSIVE
EXPANDED
PROBLEM
FOCUSED
Palmetto GBA December 2009
13
EXAMINATION
1995 GUIDELINES:
BODY AREAS
BODY SYSTEMS
•
•
•
•
•
•
•
•
•
•
HEAD
NECK
CHEST
ABDOMEN
BACK/SPINE
GENITALIA/GROIN/
BUTTOCKS
Rt UPPER EXT
Lt UPPER EXT
Rt LOWER EXT
Lt LOWER EXT
•
•
•
•
•
•
•
•
•
•
•
CONSTITUTIONAL
EYES
EARS,MOUTH,NOSE
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
INTEGUMENTARY
MUSCULOSKELETAL
NEUROLOGICAL
PSYCHIATRIC
HEM/LYMPH/IMMUNO
Palmetto GBA December 2009
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1995 Detailed Examination Example
O: Patient is alert & oriented; in no acute
distress. Skin is pink, dry, warm. Her
lungs are CTA. Heart RRR without
murmurs. Abd is soft, not distended,
+ bowel sounds. She has tenderness to
palpitation in midepigastric region. No
other tenderness, no palpable masses. BP
69/34, T97.5, P 60, R 24
Palmetto GBA December 2009
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EVALUATION AND MANAGEMENT REVIEW SHEET
ESTABLISHED PATIENT (2 of 3 E/M elements)
REVIEW OF SYSTEMS AND EXAMINATION:
ROS
EXAM
ROS
EXAM
ROS
EXAM
Constitutional
Skin/Breast
All Others Neg
N/A
Eyes
Musculoskeletal
ENT
Neurologic
Cardiovascular
Psychiatric
Head, incl. Face
Genitalia/Groin/Buttocks
Respiratory
Hem/Lymph
Neck
Right Upper Extremity
Gastrointestinal
Endocrine
N/A
Chest
Left Upper Extremity
Genitourinary
Allergy/Imm
N/A
Abdomen
Right Lower Extremity
Back/Spine
Left Lower Extremity
1995 BODY AREAS
EXAM
EXAM
B. EXAMINATION TYPE: 1997 exam guidelines must be used if HPI extended d/t status 3+ chronic/inactive conditions
1995
GuidelinesBody Areas
1995
GuidelinesSystems
1997
GuidelinesGeneral
EXAM
TYPE
Affected Area
Affected Area + 1-6
Others
Affected System
Affected System + 1-6
Others
1-5 Bulleted
elements
Prob.Focused
6-11 Bulleted elements
Exp.Prob.Focused
2-7 Areas, More
Detail
2-7 Systems,
More Detail
12 + Bulleted
elements in 2+
Systems
Detailed
Palmetto GBA December 2009
8+ Areas
8+ Systems or
Complete Single
System Exam
2+ Bulleted elements
for each or 9+
Systems
Comprehensive
16
1995 Comprehensive Examination Example
PHYSICAL EXAMINATION: This is a 72-year-old
female, alert, oriented. Vital signs: Blood pressure
96/50, respirations 20, pulse 88, temperature 97.0F
HEENT: Within normal limits. Nasopharynx: patent.
Oropharynx: mucous membranes pink and moist.
Cranial nerves II-XII are intact. Neck: Supple. Airway is
patent. Negative stridor. No lymph node adenopathy.
Chest: Heart regular. Lungs: Clear. Abdomen: Diffuse
discomfort. No focal pain. Active bowel sounds. Negative
distention. No flank pain or costovertebral angle
tenderness. Rectal examination: Negative for blood. No
masses in the rectal vault. Pelvis: otherwise intact.
Extremities: full range of motion. Radial, femoral, and
pedal pulses are palatable.
Palmetto GBA December 2009
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EVALUATION AND MANAGEMENT REVIEW SHEET
NEW PATIENT (3 of 3 E/M elements)
REVIEW OF SYSTEMS AND EXAMINATION:
ROS
EXAM
ROS
EXAM
ROS
EXAM
Constitutional
Skin/Breast
Eyes
Musculoskeletal
ENT
Neurologic
Cardiovascular
Psychiatric
Head, incl. Face
Genitalia/Groin/Buttocks
Respiratory
Hem/Lymph
Neck
Right Upper Extremity
Gastrointestinal
Endocrine
N/A
Chest
Left Upper Extremity
Genitourinary
Allergy/Imm
N/A
Abdomen
Right Lower Extremity
Back/Spine
Left Lower Extremity
B. EXAMINATION TYPE: 1997
All Others Neg
N/A
1995 BODY AREAS
EXAM
EXAM
exam guidelines must be used if HPI extended d/t status 3+ chronic/inactive conditions
1995
GuidelinesBody Areas
1995
GuidelinesSystems
1997
GuidelinesGeneral
Affected Area
Affected Area + 1-6
Others
2-7 Areas, More
Detail
Affected System
Affected System + 1-6
Others
2-7 Systems,
More Detail
1-5 Bulleted
elements
6-11 Bulleted elements
12 + Bulleted
elements in 2+
Systems
8+ Systems or
Complete Single
System Exam
2+ Bulleted elements
for each or 9+
Systems
EXAM
TYPE
Prob.Focused
Exp.Prob.Focused
Detailed
Comprehensive
Palmetto GBA December 2009
8+ Areas
18
1995 Examination FAQ
Can we consider both body areas and
organ systems together if we are using the
1995 E/M guidelines for the Examination
Component?
Answer: No. For the exam component,
you may either use body areas or organ
systems and not a combination.
Palmetto GBA December 2009
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1995 Examination FAQ
In the E/M documentation guidelines, what does ‘more
detail’ regarding the exam mean, and what is the
difference between an expanded problem-focused exam
and detailed exam?
Answer: 'More detail' refers to the extent of the exam.
The level of detail involved in an exam is a clinical
judgment based on the documentation for each
individual medical record. There is an expectation that
the exam will be more involved and therefore more
documentation would be submitted for a detailed exam.
The documentation for the detailed exam is expected to
be more explanatory, while an expanded problemfocused exam is more representative of a cursory exam.
Palmetto GBA December 2009
20
EXAMINATION
1997 GUIDELINES - SYSTEMS
GENERAL MULTISYSTEM EXAM
•
•
•
•
•
•
•
•
•
•
EYES
EARS,MOUTH,NOSE,THROAT
CARDIOVASCULAR
RESPIRATORY
GENITOURINARY
INTEGUMENTARY
MUSCULOSKELETAL
NEUROLOGICAL
PSYCHIATRIC
HEMATOLOGIC/
LYMPHATIC/IMMUNOLOGIC
Palmetto GBA December 2009
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1997 Examination Example
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Physical Exam: Tem; 95.2 BP 203/44 Resp 18 pulse 80
General Appearance: Patient is a thin, elderly, hard of hearing female in no acute distress
Orientation: Alert and oriented x 3
Memory (recent and remote), Concentration, Attention: Normal
Language: Normal
Knowledge: Normal
Funduscopic exam: Pupils equal, round, reactive to light and accommodation. Extraocular
movements intact. Funduscopic exam including posterior segments unremarkable. Fields full.
Nystagmus noted. Optic disc wnl.
Normal facial sensation identified. Slight right ptosis, otherwise normal facial symmetry.
Decreasing hearing bilaterally. Normal palatal elevation, trapezius movement and tongue
movement identified.
Strength: 5/5 upper extremities and 4/5 lower extremities
Tone: Normal no tremor.
Coordination: Finger-to-nose, heel-to-shin is normal
Reflexes: Symmetric, down-going toes. DTR nl. On sensory exam, no sensory level identified no
neglect. Pin, vibratory, and joint position sense is intact. She reports no lower extremity
paresthesias.
Gait/Station: Patient has difficulty ambulating, but able to stand with assist. Questionable leftsided ataxia.
Carotids: Without bruits.
Heart: Regular rate and rhythm. Normal S1, S2, and 4/6 systolic ejection murmur.
Peripheral vascular exam: No edema in lower extremities.
Palmetto GBA December 2009
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1997 Examination: Neurological
System/Body Area
Constitutional
*All elements must be documented.
Eyes
*All elements must be documented.
Cardiovascular
Elements of Examination
•
Measurement of any three of the following seven vital signs:
–Sitting or standing blood pressure
–Supine blood pressure
–Pulse rate and regularity
–Respiration
–Temperature
–Height
–Weight (may be measured and recorded by ancillary staff)
• General appearance of patient (e.g., development, nutrition, body
habitus, deformities, attention to grooming)
• Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio,
appearance) and posterior segments (e.g., vessel changes, exudates,
hemorrhages)
• Examination of carotid arteries (e.g., pulse amplitude, bruits)
• Auscultation of heart with notation of abnormal sounds and murmurs
• Examination of peripheral vascular system by observation (e.g.,
swelling, varicosities) and palpation (e.g., pulses, temperature, edema,
tenderness)
Palmetto GBA December 2009
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1997 Examination: Neurological
System/Body Area
Musculoskeletal
*All elements must be documented.
Elements of Examination
• Examination of gait and station
Assessment of motor function including:
• Muscle strength in upper and lower extremities
• Muscle tone in upper and lower extremities (e.g., flaccid, cog wheel,
spastic) with notation of any atrophy or abnormal movements (e.g.,
fasciculation, tardive dyskinesia)
Neurological
*All elements must be documented.
Evaluation of higher integrative functions including:
• Orientation to time, place and person
• Recent and remote memory
• Attention span and concentration
• Language (e.g., naming objects, repeating phrases, spontaneous speech)
• Fund of knowledge (e.g., awareness of current events, past history, vocabulary)
Test the following cranial nerves:
• Second cranial nerve (e.g., visual acuity, visual fields, fundi)
• Third, fourth and sixth cranial nerves (e.g., pupils, eye movements)
• Fifth cranial nerve (e.g., facial sensation, corneal reflexes)
• Seventh cranial nerve (e.g., facial symmetry, strength)
• Eighth cranial nerve (e.g., hearing with tuning fork, whispered voice and/or finger
rub)
• Ninth cranial nerve (e.g., spontaneous or reflex palate movement)
• Eleventh cranial nerve (e.g., shoulder shrug strength)
• Twelveth cranial nerve (e.g., tongue protrusion)
• Examination of sensation (e.g., by touch, pin, vibration, proprioception)
• Examination of deep tendon reflexes in upper and lower extremities with notation of
pathological reflexes (e.g., Babinski)
• Test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements in
the upper
andDecember
lower extremities,
evaluation of fine motor coordination in young children)
Palmetto
GBA
2009
24
1997 Examination: Neurological
Level of Exam
Perform and Document
Problem Focused
One to five elements identified by a bullet.
Expanded Problem-Focused
At least six elements identified by a bullet.
Detailed
At least 12 elements identified by a bullet.
Comprehensive
•
•
•
Perform all elements identified by a bullet
Document every element in a box with a
shaded border
Document at least one element in each
box with an unshaded border
Palmetto GBA December 2009
25
Resources
• www.cms.hhs.gov/manuals/IOM/list.asp
– Pub.100-04 Chapter 12
– Pub.100-08 Chapter 3
• Current Procedural Terminology CPT 2009
• www.palmettogba.com/boh for OH
www.palmettogba.com/bsc for SC
www.palmettogba.com/bwv for WV
– Browse by Topic: E/M Help Center
– Browse by Specialty: additional articles
– CERT: example letters, and graphs by specialty
• www.cms.hhs.gov/cert
– Overview; and
– CERT reports
Palmetto GBA December 2009
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