Choose Your Exam Rules

The Hospitalist. 2008 May;2008(05):

May 1, 2008|The Hospitalist

Physicians only should perform patient examinations based upon the presenting problem and the standard of care. As mentioned in my previous column (April 2008, p. 21), the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) set forth two sets of documentation guidelines. The biggest difference between them is the exam component.

1995 Guidelines

The 1995 guidelines distinguish 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).

Further, these guidelines let physicians document their findings in any manner while adhering to some simple rules:

Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems; and
Elaborate on abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

Physician Alert

On Feb. 22, CMS issued written clarification for discharge day management services. Many Medicare contractors, consultants, and educators had been instructing physicians to report discharge day management services (CPT 99238-99239) only when the physician provides a face-to-face encounter with the patient. CMS confirmed this in Transmittal 1460 (Change Request 5794).

Additionally, CMS clarified when discharge day management can be reported (www.cms.hhs.gov/transmittals/downloads/R1460CP.pdf). Effective April 1:

The discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner, even if the patient is discharged from the facility on a different calendar date; and
The date of the pronouncement shall reflect the calendar date of service on the day it was performed, even if the paperwork is delayed to a subsequent date.

This second clarification varies from previous instruction that only allowed the physician to report 99238 or 99239 on the last day of the inpatient stay. Now, the physician can perform the necessary components and report discharge day management (e.g., final face-to-face visit with the patient, approve and/or the patient’s discharge, provide additional patient instruction as necessary) on the day before the patient leaves the facility. If physician documentation on the day prior to discharge does not include a statement about the patient’s discharge, it would be more appropriate to report subsequent hospital care (99231-99233).—CP

1997 Guidelines

The 1997 guidelines comprise bulleted items—referred to as elements—that correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.

For example, the physician only receives credit for documentation of vital signs (an element of the constitutional system) when three measurements are referenced (e.g., blood pressure, heart rate, and respiratory rate). Documentation that does not include three measurements or only contains a single generalized comment (e.g., vital signs stable) cannot be credited to the physician in the 1997 guidelines—even though these same comments are credited when applying the 1995 guidelines.

This logic also applies to the lymphatic system. The physician must identify findings associated with at least two lymphatic areas examined (e.g., “no lymphadenopathy of the neck or axillae”).

Elements that do not contain numeric criterion but identify multiple components require documentation of at least one component. For example, one psychiatric element involves the assessment of the patient’s “mood and affect.” If the physician comments that the patient appears depressed but does not comment on a flat (or normal) affect, the physician still receives credit for this exam element.