By Kathy Mills Chang, MCS-P
Make sure you know how to fulfill the “examination” component. In part one of this series, the components of a patient’s history were reviewed, and you learned how it is the first of three elements that help you justify and document your evaluation and management (E/M) service.
In the second part of this series, you’ll learn about the objective information required to properly document the examination.
Remember, the medical record establishes a chronological record of exams; tests and results; treatments; and treatment plans, including the diagnosis and prognosis of the illness or disease. Its job is to corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.
For this reason, your medical record is a vital piece of the reimbursement puzzle, too. Understanding all the requirements, including those of the examination, is critical.
There are four levels of E/M services that are based on four types of examinations:
1. Problem focused examination. This is a limited examination of the affected body area or organ system that the patient presented with.
2. Expanded problem-focused examination. This is a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).
3. Detailed examination. This is an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area or organ system.
4. Comprehensive examination. This is a general multisystem examination, or complete examination of a single organ system and any other symptomatic or related body area or organ system.
Centers for Medicare and Medicaid Services (CMS) has defined these types of examinations for general multisystem and the following single organ systems:
* Ears, nose, mouth, and throat;
* Genitourinary (female);
* Genitourinary (male);
* Respiratory; and
A general multisystem examination or a single organ system examination may be performed by any physician regardless of specialty. The type (general multisystem or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).
The musculoskeletal examination
Most chiropractors use the musculoskeletal, single organ system examination to base their coding and work. This examination contains not only musculoskeletal examination components, but also skin, lymphatic, cardiovascular, neurological, and other components.
A clear understanding of these examination findings ensures that your documentation is sufficient to meet your
health Source coding. Additionally, make sure your examination is complete enough to substantiate the history taken in step one.
Ensure that you clearly understand the bullets/steps in the examination process, particularly the musculoskeletal category. The following bulleted items are those specific elements that are outlined and described for documentation and should be considered in your examination:
Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four 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, percussion, and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses, or effusions;
* Assessment of range of motion with notation of any pain (e.g., straight leg raising), 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.
Gait, station examination
Check your examination paperwork or EHR system to ensure that each of these tests and measurements are a regular part of your examination procedure. Depending on the number of regions examined, bullets completed, and tests performed, you can figure out the level of examination performed, as noted in the categories above.
The beauty of these examination guidelines is that the requirements are laid out in front of you in impeccable order. Some doctors may have never seen these guidelines, and yet they were published in 1997.
Stay up to date on the rules and requirements, but also constantly review, improve, and upgrade your examination technique and systems. Using the published E/M guidelines is a simple way to ensure that you are compliant with coding and documentation, and are meeting all the elements you’re expected to meet to render a diagnosis and plan of care.
Careful implementation of all the E/M documentation guidelines will ensure your coding is accurate, your examination is supporting your treatment recommendations, and you are complying with the CMS requirements.
You are now two-thirds of the way to perfected, compliant E/M coding! Look for more information on the last key component — medical decision making — in a future issue of this magazine.
Kathy Mills Chang is the founder of her own consulting firm assisting doctors with finding financial and reimbursement ease in practice. She also serves as Foot Levelers’ insurance adviser and can be reached at 888-659-8777 or firstname.lastname@example.org.