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Levels of Exam
There are four levels of exam, determined by the number of elements documented in the progress note (see Tables 1A and 1B, p. below).
As with the history component, the physician must meet the requirements for a particular level of exam before assigning it. The most problematic feature of the 1995 guidelines involves the “detailed” exam. Both the expanded problem-focused and detailed exams involve two to seven systems/areas, but the detailed exam requires an “extended” exam of the affected system/area related to the presenting problem. Questions surround the number of elements needed to qualify as an “extended” exam of the affected system/area.
Does “regular rate and rhythm; normal S1, S2; no jugular venous distention; no murmur, gallop, or rub; peripheral pulses intact; no edema noted” constitute an “extended” exam of the cardiovascular system, or should there be an additional comment regarding the abdominal aorta? This decision is left to the discretion of the local Medicare contractor and/or the medical reviewer.
Since no other CMS directive has been provided, documentation of the detailed exam continues to be inconsistent. More importantly, review and audit of the detailed exam remains arbitrary. Some Medicare contractors suggest using the 1997 requirements for the detailed exam, while others create their own definition and corresponding number of exam elements needed for documentation of the detailed exam. This issue exemplifies the ambiguity for which the 1995 guidelines often are criticized.
Meanwhile, the 1997 guidelines often are criticized as too specific. While this may help the medical reviewer/auditor, it hinders the physician. Physicians are frequently frustrated trying to remember the explicit comments and number of elements associated with a particular level of exam.
One solution is documentation templates. Physicians can use paper or electronic templates that incorporate cues and prompts for normal exam findings, incorporating adequate space to elaborate abnormal findings.
Remember the physician has the option of utilizing either the 1995 or 1997 guidelines, depending upon which set he perceives as easier to implement.
Additionally, auditors must review physician documentation using both the 1995 and 1997 guidelines, and apply the most favorable result to the final audit score.
Each type of evaluation and management service identifies a specific level of exam that must be documented in the medical record before the associated CPT code is submitted on a claim.
The most common visit categories provided by hospitalists and corresponding exam levels are outlined in Table 2 (above). Similar to the history component, other visit categories, such as critical care and discharge day management, do not have specified levels of exam or associated documentation requirements for physical exam elements. TH