More Help With Exam Documentation

The bulk of the revised guidelines attempt to define single-organ-system exams and establish documentation requirements.

Kent J. Moore and Leigh Ann Henry

The latest overhaul of Medicare's exam documentation guidelines began as an attempt to explain what is meant by a complete examination of a single organ system -- "the other half" of Medicare's definition of a comprehensive exam. The newly revised and expanded guidelines define complete exams for 11 organ systems in addition to expanding the definitions for various multisystem exams. (For an explanation of the new criteria for various levels of multisystem exam, see the companion article "Exam Documentation Just Got Harder," page 75 in our October issue.) While family physicians are generally much more likely to perform multisystem exams than single-system exams, the new definitions should enable you to document any intensive single-system exams you do perform with greater confidence that you'll survive Medicare's scrutiny.

And depending on the nature of your practice, you may find yourself using the definitions for exams of at least one or two systems with some regularity. Douglas E. Henley, MD, past president of the AAFP and a member of the AMA CPT Editorial Panel, points out that family physicians who practice sports medicine or see lots of patients with musculoskeletal problems may find the musculoskeletal exam definition particularly useful, and those who provide a lot of well-woman care may find themselves using the female GU exam definition frequently.

In this article, we'll give you an overview of the single-system exam guidelines. A third article on the new guidelines will be published in our January issue. That article will feature tools you can use to make documenting exams less difficult, including a revised version of our original "Pocket Guide to the Documentation Guidelines."¹

User's Guide

The definitions for all the single-system exams were developed jointly by the AMA and HCFA, with input from medical specialty societies. The following 11 exams are defined in the revised guidelines: cardiovascular; ears, nose, mouth and throat; eyes; genitourinary (female); genitourinary (male); hematologic/lymphatic/immunologic; musculoskeletal; neurological; psychiatric; respiratory; skin.

For the sake of illustration, we've reproduced a chart that includes the clinical elements for the comprehensive cardiovascular system exam. You can access charts for the other organ systems and the rest of the guidelines at the HCFA web site (http://www.hcfa.gov/medicare/mcarpti.htm), by contacting your Medicare carrier or by calling the AAFP Order Department (800-944-0000). Because of press deadlines, the 1998 version of the CPT manual won't include the guidelines.

Charts detail the elements of each exam. Within each chart, headings list the organ systems and body areas as CPT categorizes them. The elements of the exam are identified by bullets (*). Organ systems and body areas that include elements essential to the exam are shaded. Organ systems and body areas that include elements that are pertinent, but not essential, to the exam are not shaded. Organ systems or body areas that are not pertinent to the exam are listed without elements.

As with the general multisystem exam, parenthetical examples provide clarification and guidance within the chart. Any numeric requirements included in the description of the element (such as "Measurement of any three of the following seven ... ") must be satisfied. Elements that have multiple components but that include no specific numeric requirement (such as "Examination of liver and spleen") require documentation of at least one of the components. No substitutions may be made for the items listed, and because the clinical elements are minimum standards for comprehensive exams, physicians shouldn't feel the need to make substitutes, according to HCFA.

Three basic documentation guidelines, which are applicable regardless of the level or type of exam, bear repeating:

Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient.
Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
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).

The exam requirements

As we mentioned earlier, the revised guidelines originated as an attempt to define a comprehensive exam of a single organ system. The final product, however, establishes requirements for all four levels of exam (the table "Single-organ-system exam content and documentation requirements," page 71, summarizes the requirements). To qualify for a given level of single-system exam, the following standards must be met:

Problem focused: performance and documentation of one to five elements identified by a bullet;
Expanded problem focused: performance and documentation of at least six elements identified by a bullet;
Detailed: performance and documentation of at least 12 elements identified by a bullet (note this exception: eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet);
Comprehensive: performance of all elements identified by a bullet and documentation of every element in each shaded box and at least one element in each unshaded box.

It's worth noting that although the clinical elements distinguish the general multisystem exam from the single-system exam, the performance and documentation requirements for the first three levels of exam (problem focused, expanded problem focused and detailed) are essentially the same for both types of exam. For example, in either case, you must perform and document at least six elements identified by a bullet to qualify for an expanded problem focused exam. Remembering these similarities between the requirements may make the guidelines easier to manage when the time comes for you to use them.

Cardiovascular examination

*Constitutional

Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (may be measured and recorded by ancillary staff)
General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Eyes

Inspection of conjunctivae and lids (e.g., xanthelasma)

Ears, Nose, Mouth and Throat

Inspection of teeth, gums and palate
Inspection of oral mucosa with notation of presence of pallor or cyanosis

Neck

Examination of jugular veins (e.g., distention; a, v or cannon a waves)
Examination of thyroid (e.g., enlargement, tenderness, mass)

*Respiratory

Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

*Cardiovascular

Palpation of heart (e.g., location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S₃ or S₄)
Auscultation of heart including sounds, abnormal sounds and murmurs
Measurement of blood pressure in two or more extremities when indicated (e.g., aortic dissection, coarctation)

Examination of:

Carotid arteries (e.g., waveform, pulse amplitude, bruits, apical-carotid delay)
Abdominal aorta (e.g., size, bruits)
Femoral arteries (e.g., pulse amplitude, bruits)
Pedal pulses (e.g., pulse amplitude)
Extremities for peripheral edema and/or varicosities

*Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness
Examination of liver and spleen
Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Musculoskeletal

Examination of the back with notation of kyphosis or scoliosis
Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs
Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

Extremities

Inspection and palpation of digits and nails (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler's nodes)

Skin

Inspection and/or palpation of skin and subcutaneous tissue (e.g., stasis dermatitis, ulcers, scars, xanthomas)

*Neurologic/Psychiatric

Brief assessment of mental status, including:

Orientation to time, place and person;
Mood and affect
(e.g., depression,
anxiety, agitation)

Note: This exam includes no elements in the following systems and body areas: Head and Face; Chest (Breasts); Genitourinary; Lymphatic.

Second, like the guidelines for the comprehensive general multisystem exam, the guidelines for comprehensive single-system exams distinguish between what you are expected to perform and what you are expected to document. (Medicare's rationale is that they want to ensure that the physician work going into the exam justifies the level of reimbursement, while relieving the physician's documentation burden.) The shading of boxes in the single-system charts complicates matters somewhat. The guidelines indicate that, for a comprehensive single-system exam, you should perform all elements identified by a bullet and document every element in each shaded box but you need only document one element in each unshaded box.

Despite the distinction, you and your patient will probably be better served if you document everything you do; that way, if you can't remember that the documentation requirements differ according to the shade of the box, it's not a stumbling block.

Single-organ-system exam content and documentation requirements

Exam Type	Requirements	Bulleted Elements
Problem focused	Perform and document one to five elements identified by bullets.	1-5
Expanded problem focused	Perform and document at least six elements identified by bullets.	6-11
Detailed	Perform and document at least 12 elements identified by bullets.*	12+
Comprehensive	Perform all elements identified by bullets; document every element in each shaded box and at least one element in each unshaded box.	Varies by organ system
For eye and psychiatric exams, at least nine elements identified by a bullet must be performed and documented.*

Practicing within the guidelines

To see what all this means in context, let's apply the guidelines to a sample note. The patient is a 55-year-old man with hypertension who presents with increasing shortness of breath and edema.

Compare the following note with the chart for the cardiovascular exam:

BP 126/86, P 82, WT 190. Pt. appears tired. HEENT: conjunctivae WNL w/o erythema; PERRLA, EOMs intact; TMs nl; oropharynx benign w/o pallor. NECK: supple w/o JVD, bruits or thyromegaly. RESP: lungs clr to percussion and auscultation w/o retractions or rubs. CV: hs WNL w/o gallop, murmur, rub or thrill; no bruits were noted of the aorta or femoral arteries. GI: abdomen soft, non-tender w/o organomegaly or masses; bowel sounds WNL; no guarding or rebound tenderness. MUSC: back w/o CVA tenderness, scoliosis or kyphosis. EXT: distal pulses intact w/o cyanosis or clubbing; 2+ pedal edema was noted. SKIN: WNL w/o stasis dermatitis or ulcers. NEURO: patient was oriented x 3; affect appeared normal.

The note documents every element in each shaded box and at least one element in each unshaded box. If all elements in the chart have been performed (and the medical necessity standard is met), the exam qualifies as comprehensive. Here's how the note and the bulleted elements in the chart match up:

Constitutional: Measurement of any three of the following seven vital signs ... ("BP 126/86, P 82, WT 190");
Constitutional: General appearance of the patient ("Pt. appears tired");
Eyes: Inspection of conjunctivae and lids (HEENT: "conjunctivae WNL w/o erythema");
Ears, Nose, Mouth and Throat: Inspection of oral mucosa with notation of presence of pallor or cyanosis (HEENT: "oropharynx benign w/o pallor");
Neck: Examination of the jugular veins (NECK: "supple w/o JVD, bruits or thyromegaly");
Neck: Examination of thyroid (NECK: "supple w/o JVD, bruits or thyromegaly");
Respiratory: Assessment of respiratory effort (RESP: "lungs clr to percussion and auscultation w/o retractions or rubs");
Respiratory: Auscultation of lungs (RESP: "lungs clr to percussion and auscultation w/o retractions or rubs");
Cardiovascular: Palpation of heart (CV: "hs WNL w/o gallop, murmur, rub or thrill");
Cardiovascular: Auscultation of heart including sounds, abnormal sounds and murmurs (CV: "hs WNL w/o gallop, murmur, rub or thrill");
Cardiovascular: Examination of carotid arteries (NECK: "supple w/o JVD, bruits or thyromegaly");
Cardiovascular: Examination of abdominal aorta (CV: "no bruits were noted of the aorta or femoral arteries");
Cardiovascular: Examination of femoral arteries (CV: "no bruits were noted of the aorta or femoral arteries");
Cardiovascular: Examination of pedal pulses (EXT: "distal pulses intact w/o cyanosis or clubbing; 2+ pedal edema was noted");
Cardiovascular: Examination of extremities for peripheral edema and/or varicosities (EXT: "distal pulses intact w/o cyanosis or clubbing; 2+ pedal edema was noted");
Gastrointestinal: Examination of abdomen with notation of presence of masses or tenderness (GI: "abdomen soft, non-tender w/o organomegaly or masses; bowel sounds WNL; no guarding or rebound tenderness");
Gastrointestinal: Examination of liver and spleen (GI: "abdomen soft, non-tender w/o organomegaly or masses");
Musculoskeletal: Examination of the back with notation of kyphosis or scoliosis (MUSC: "back w/o CVA tenderness, scoliosis or kyphosis");
Extremities: Inspection and palpation of digits and nails (EXT: "distal pulses intact w/o cyanosis or clubbing; 2+ pedal edema was noted");
Skin: Inspection and/or palpation of skin and subcutaneous tissue (SKIN: "WNL w/o stasis dermatitis or ulcers");
Neurologic/Psychiatric: Brief assessment of mental status, including orientation to time, place and person (NEURO: "patient was oriented x 3");
Neurologic/Psychiatric: Brief assessment of mental status, including mood and affect (NEURO: "affect appeared normal").

The following two elements are necessary to perform and document only under certain circumstances. Neither was indicated for the patient in our sample exam:

Gastrointestinal: Obtain stool sample for occult blood (necessary only if patient were "being considered for thrombolytic or anticoagulant therapy," according to the guidelines);
Cardiovascular: Measurement of blood pressure in two or more extremities (necessary only "when indicated," according to the guidelines).

Note that the comprehensive cardiovascular exam requires that 11 systems or body areas be examined and that 23 elements be documented. That's five elements and two organ systems or body areas more than the comprehensive general multisystem exam, which requires documentation of 18 elements, or two elements from each of nine organ systems or body areas. In fact, the documentation in our sample note goes far beyond the documentation requirements for the comprehensive general multisystem exam (see the general multisystem exam table on pages 78-79 of our October issue). Like the single-system exam, the multisystem exam requires that all specified elements be performed. The elements differ, and the general multisystem exam includes one body area and two systems that are not represented in the cardiovascular exam: Chest (Breasts), Genitourinary and Lymphatic.

Whichever type of exam you choose to perform and document, we suggest that you note it on the chart to avoid potential confusion during an audit. For the time being, HCFA has decided against designating a modifier to be used for this purpose.

Parting advice

If these guidelines seem even more confusing than the general multisystem exam guidelines, that's probably because they are. Indeed, if their initial reaction is any indication, subspecialists who devote their whole careers to single organ systems may have an even tougher time than family physicians at putting the new guidelines into practice. We're just over a month into the grace period (the guidelines take full effect on Jan. 1, 1998), but subspecialists have already voiced numerous concerns to HCFA and the AMA, including assertions that some exam elements aren't linked to medical necessity and that asking a physician to examine something he or she doesn't feel comfortable doing will create "a feeding frenzy" for malpractice attorneys.

Advice for teaching physicians

Some family physicians have wondered how the revised guidelines affect teaching physicians' documentation and that of community preceptors in particular. Aron Primack, MD, a medical officer in HCFA's Program Integrity department, addressed this issue at a recent AMA-sponsored meeting about the guidelines.

He noted that HCFA regards the medical record as a combination of the resident's and the teaching physician's notes. As such, the teaching physician does not have to rewrite everything written by the resident. However, the teaching physician must add value to the service as evidenced by the documentation and be present for the key portion of the service, unless the primary care exception is met ("New Medicare Rules for Paying Teachers and Residents," FPM, June 1996, page 21, explains the primary care exception in detail). Primack said it is permissible for residents to generate the documentation for a teaching physician's service. In such cases, he said, both the resident and the teaching physician must be present, the resident must note the teaching physician's presence in the medical record and the teaching physician must sign the record.

Despite the protests, HCFA and the AMA have no immediate plans to further revise the guidelines, but representatives of the organizations say they will issue clarifications as necessary. The AMA CPT Editorial Panel has meetings scheduled in November, February and May. We'll report on any pertinent developments in FPM's Medicare Update department.

The AMA and HCFA developed the documentation guidelines for single-system exams to fill a void. You may well find the general multisystem exam guidelines easier to use. Whichever you need to use, we suggest you do whatever you can to make the guidelines work. (The article we're developing for our January issue will help.) HCFA has still not determined the methodology by which Medicare carriers will select E/M claims for random prepayment review, but as many as 3 percent of claims may be subject to review. If your claims are reviewed, you will be in a more comfortable position if you know you have back-up for them in the form of documentation that conforms to the guidelines.

¹All three articles will be incorporated into a new edition of Mastering Medicare's New Documentation Guidelines, the FPM publication designed to help family physicians cope with the added complexities of the guidelines. Watch FPM for announcements of the new edition's availability early in 1998.

Kent Moore is the AAFP's manager for reimbursement issues. Leigh Ann Henry is an associate editor of Family Practice Management.