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How many systems need to be documented for a detailed exam?
Question: I’m getting some conflicting information about what I need to have to support a “detailed exam.” One coder tells me I need to document seven organ systems while a colleague tells me that I can get by with as little as two or three if there is more detail. What’s the rule here?
Answer: This speaks to the CPT code component definitions, those same definitions as adopted by the 1995 Federal Documentation Guidelines, the 1997 Guidelines, and most importantly - how these are interpreted and applied by a given reviewer looking at your documentation.
First the definition from CPT and the 1995 guidelines: “Detailed - an extended examination of the affected body area(s) and other symptomatic or related organ system(s).”
This does not specify a given number of systems. The description for the “expanded problem focused” level below it requires “a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).” This also doesn’t give a count of systems. The difference is in “a limited exam” or “an extended exam” of a given area (or organ system) and some other number of systems.
These descriptions are close to 20 years old and just as vague now as when they were written. Since a problem focused exam is one system (it’s singular) and the comprehensive is eight (it says so), then both the expanded problem focused and detailed are somewhere between two and seven - and beyond that we really don’t know.
Some conventional wisdom says that two to four systems examined looks like the lesser of the two, while five to seven should satisfy the need for more. So there is some safety in the coder’s position that seven is good - certainly safe - if not required. For several of these systems, “A brief statement or notation indicating ‘negative’ or ‘normal’ is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).” For those affected systems, or those involving the chief complaint, some narrative or depth would be expected.
Can you have a detailed exam with only two or three systems? I’d say you could - if the detail provided within the affected system appeared detailed. But here we are very much in the place of what does the note “feel” like as opposed to a specific count. You are in the court of the auditor now.
To be safe, really safe here, be sure that for two to three systems you cover 12 bullet points from the 1997 guidelines. This set of rules isn’t better, just different - it allows for specificity within a given system or area. The 1995 set actually allows less specificity. If you can get 12 of these points or elements, you’ve met the “detailed” exam under the more exacting standard.
In my opinion, even close to 12 points should be enough. With the exception of EHRs and templates, physicians don’t usually write more than they have to. Any reasonable auditor should be able to see the difference between a somewhat limited exam and one involving meaningful detail. So there is no magic number, it’s your call - and the auditor’s.
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at email@example.com or firstname.lastname@example.org.
This question originally appeared in the September 2010 issue of Physicians Practice.