Evaluation and Management Services: Physical Examination

Abstract

The May and June 2006 issues of Pediatric Coding Companion™ (Volume 1, numbers 8 and 9) addressed guidelines and documentation requirements to determine the appropriate levels of medical decision making and history when selecting an evaluation and management (E/M) service code. This issue will focus on the guidelines and documentation requirements for the key component of physical examination.The Centers for Medicare and Medicaid Services (CMS), state Medicaid programs, and most commercial payers rely on the 1995 or 1997 Documentation Guidelines for E/M Services as their requirements for reporting E/M services. The major difference in these guidelines is the definition of the physical examination component. The guidelines are clear that a general multisystem or single organ system examination is not specialty specific. The 1997 guidelines are very specific when addressing the performance of physical examination and documentation requirements. The 1995 guideline requirements are less complex with fewer bullet points and are therefore perceived as more forgiving. Both sets of guidelines are summarized as follows to allow for better understanding of this key component.The extent of the examination performed is dependent on the physician’s clinical judgment, patient’s history, and problems or conditions addressed during the course of the visit. Body areas include the abdomen, back (including spine), chest (includ-ing breast and axillae), genitalia or groin, buttocks, head and face, each extremity, and neck. Organ systems recognized include constitutional (general appearance, vital signs); cardiovascular; ears, nose, mouth, and throat; eyes; gastrointestinal; genitourinary; musculoskeletal; neurologic; psychiatric; respiratory; skin; and hematologic, lymphatic, or immunologic.There are 4 levels of physical examinations defined under the guidelines (Table 1).All body areas and organ systems examined must be documented individually with relevant positive or negative findings appropriate to that area or system. Documentation of normal or negative is acceptable on any examined body area(s) or system(s) with the exception of the area(s) or system(s) that are symptomatic or affected. Pertinent findings from the physical examination must be documented for each affected or symptomatic area or system. All abnormal findings must be documented. The medical record must clearly indicate the areas or systems examined.Use of a checklist or template is acceptable. If a checklist is used to document the examination, written descriptions with positive or negative findings should be documented for any area or system related to the problem or complaint. Using a line drawn down a checklist is not sufficient unless the documentation very clearly defines the exact system and area examined. Most coders and auditors will advise physicians and physician extenders not to use lines but to define the area or system examined more clearly by using a check mark or circle.Documentation of a comprehensive-level examination under the 1995 guidelines should include specific findings for at least 8 organ systems. A checklist without any specific findings, whether negative or normal, does not truly constitute a comprehensive (ie, thorough) examination.While it may be a physician’s preference to perform a detailed or comprehensive examination at every visit, only the level of physical examination that is medically necessary should be used in the selection of the code.Acceptable documentation is shown in Table 2 or could be as follows:Physical examination. General—temperature 97.5°F, no acute distress. Ears, nose, and throat—nasal congestion; right tympanic membrane erythematous and bulging; left tympanic membrane clear and gray. Neck—without lymphadenopathy. Lungs—clear to auscultation. Cardiovascular—regular rate and rhythm without murmur. Abdomen—soft, non-tender, positive bowel sounds. Skin—normal.A 15-year-old established patient presents with abdominal pain.Physical examination. General—temperature normal, height and weight appropriate to age, well developed, well nourished. Eyes—pupils equal and reactive to light. Ears, nose, and throat—tympanic membranes normal, nasopharynx normal. Neck—without lymphadenopathy, tenderness, or masses; thyroid normal. Chest—normal. Lungs—normal. Abdomen—soft, no masses, tenderness to palpation, no rebound, increased bowel sounds; normal sphincter tone, guaiac negative, no hepatosplenomegaly. Genitourinary— external genitalia normal, cervix normal without discharge. Back—no tenderness, normal range of motion. Neurologic— normal. Skin—normal. Psychologic—normal mood and affect.1995 guidelines—this would be considered a comprehensive-level examination because 8 or more organ system(s) were examined. Documentation reflects specific findings on 8 systems.1997 guidelines—this would be considered a detailed-level examination because 2 elements from 7 areas or systems were documented. A comprehensive examination requires documentation of at least 2 elements identified by a bullet (•) from each of 9 areas or systems. While the required number of elements might have been performed, the documentation in this example does not support a comprehensive-level examination.This example demonstrates the importance of clear, concise, and thorough documentation. It is not meant to discourage any physician from using the 1997 guidelines—again, these guidelines are particularly beneficial to a specialist.Remember that the physical examination is only 1 of the 3 key components required in the selection of an E/M service.