NGS, the Medicare Administrative Contractor for the New England states recently changed how it defines a detailed exam using the 1995 guidelines. This has caused quite a stir amongst coders and practitioners in New England. It doesn’t follow the CMS/AMA 1995 guidelines, and it is a change from NGS’s own prior guidance. AAPC members, I’m sure you saw the article in the April 2017 journal.
Here’s how the original CMS/AMA 1995 guidelines described an expanded problem focused exam and a detailed exam:
“Expanded Problem Focused — a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). “
“Detailed — an extended examination of the affected body area(s) and other symptomatic or related organ system(s).”
The problem-focused exam was described as a single body area or organ system and a comprehensive exam was eight organ systems (not body areas). That meant that both an expanded problem focused exam and a detailed exam had 2-7 body areas/organ systems, one limited and one extended.
The problem was, neither CMS nor the AMA defined “limited” or “extended,” leaving it open to interpretation. (The 1997 exam was much more descriptive but not more appreciated by many.) In response, some Medicare carriers and auditors used 2-4 body areas/organ systems for an EPF exam and 5-7 for a detailed exam. You can find numerous audit sheets that are set up that way, and NGS’s prior learning tool was, too. 2-4 and 5-7 weren’t defined in the original guidelines, but did provide a specific way for auditors to audit and teachers to teach.
I don’t think the 2-4 and 5-7 scheme didn’t work for certain specialties such as GYN or Orthopedics. A physician may have done a complete pelvic exam, documented vital signs, GI and lymph nodes. When I audited that record, I called it detailed as defined in the original guidelines. It was “an extended examination of the affected body area(s) and other symptomatic or related organ system(s).” That required me to make a judgment call about whether the exam was extended or not, but I’m an auditor and it’s my job to make judgment calls.
NGS’s new definitions
But, as I like to say, that was then and this is now. If your MAC is NGS, and you are submitting Medicare claims to them, you need to use their new guidelines.
Here’s the exact wording for an expanded problem focused exam:
2–5 areas or systems (Minimal detail for areas and/or systems examined; check list type documentation without any expansion of documentation of findings).
A detailed exam is: 6–7 areas or systems (Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon)
Are you as confused as I am? Here’s what I can say for sure:
- To be absolutely sure you are meeting the exam requirements, consider using the 1997 exam. NGS’s description of the 1997 detailed exam is 12 bullets in 2 or more body areas/systems or 2 bullets in 6 or more body areas/ systems (except eye and psych exams, which are 9 bullets)
- A detailed exam using NGS’s new guidelines must have 6 or 7 body areas or organ systems. The lists of body areas and organ systems are below. I think this is going to hit certain specialties harder than others, including GYN and Ortho.
- The findings should be described. Instead of “CV: normal” it should describe the positive or negative finding, such as “CV: regular rate and rhythm.” Instead of “ENT: grossly normal” it should read “ENT: throat clear.” Describe the findings, whether they are positive or negative.
- Check list documentation of the exam won’t meet the requirements without a description. The mention of check lists seems odd to me. Check lists were used for paper documentation. Do your remember the old ED t-notes, that listed the organ system and the provider made a check mark or X on the page? I don’t see those in use any more, now that most groups have made the change to electronic health records.
Keep in mind that these are NGS guidelines. Not Medicare guidelines for other MACs. Not AMA guidelines for other payers.
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