Exam Guidelines

• Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.

Musculoskeletal

• Examination of gait and station;
• Inspection and/or palpation of digits and nails (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);
• Examination of joints, bones and muscles of one or more of the following six areas:
  1. head and neck;
  2. spine, ribs and pelvis;
  3. right upper extremity;
  4. left upper extremity;
  5. right lower extremity; and
  6. left lower extremity.

The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;
• Assessment of range of motion with notation of any pain, crepitation or contracture;
• Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and
• Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

• Inspection of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers); and
• Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening).

Neurologic

• Test cranial nerves with notation of any deficits;
• Examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski); and
• Examination of sensation (e.g. by touch, pin, vibration, proprioception).

Psychiatric

• Description of patient’s judgment and insight;
• Brief assessment of mental status, including:
  • Orientation to time, place, and person;
  • Recent and remote memory; and
  • Mood and affect (e.g. depression, anxiety, agitation).

Considerations

The 1997 Documentation Guidelines often are criticized for their “specific” nature. Although this assists the auditor, it hinders the physician. The consequence is difficulty and frustration with remembering the explicit comments and number of elements associated with each level of exam. As a solution, consider documentation templates—paper or electronic—that incorporate cues and prompts for normal exam findings with adequate space for elaboration of abnormal findings.

Remember that both sets of guidelines apply to visit level selection, and physicians may utilize either set when documenting their services. Auditors will review documentation with each of the guidelines, and assign the final audited result as the highest visit level supported during the comparison. Physicians should use the set that is best for their patients, practice, and peace of mind.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, Ill.: American College of Chest Physicians; 2009:87-118.
2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Sept. 12, 2011.
3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Sept. 12, 2011.
4. Highmark Medicare Services. Frequently Asked Questions: Evaluation And Management Services (Part B). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#10. Accessed Sept. 14, 2011.
5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at: http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Sept. 15, 2011.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.