Exam Documentation: Charting Within the Guidelines

The good news is that the new exam documentation guidelines won't complicate your life much; the bad news is that they may not help much, either.

Robert L. Edsall and Kent J. Moore

Suppose, for the sake of argument, that government regulations were invasive procedures. On the scale of invasiveness, then, HCFA's new documentation guidelines would be just a pinprick; just an injection -- an immunization, maybe. You may find them momentarily annoying, but like an immunization, they may confer long-term protection -- in this case, protection against downcoding and audit liability. They're worth going through, and that's just what we're doing in this series of articles.

The first of the series, on the history guidelines, was published last month (see "Don't Read This Article," February 1995, page 47). In this month's article, we'll tackle the examination guidelines, and we'll deal with guidelines for documenting medical decision-making in the next installment.

The guidelines for documenting exams build on what you already know from the CPT manual in three ways. First, they specify the classifications of body parts and organ systems that Medicare carriers will recognize in evaluating documentation. Second, they offer some indication of how much or how little you actually need to write down. Third, they specify the number of systems that need to be documented for a general multisystem exam. And, for the moment, at least, they also leave a lot unclear.

The framework of examination types is unchanged from what you're used to except in one respect: The definition of a comprehensive exam is one word shorter in the guidelines and the 1995 CPT manual. The word specialty has been deleted from "a general multisystem examination or complete specialty examination of a single organ system." While that doesn't change the substance of the definition, it does remove the invidious and misleading implication that only specialists in a given organ system can perform or be paid for a complete examination of that system.

Working from the lowest to the highest level, let's see how the guidelines have affected the process of determining the level of exam. You may want to refer to the guidelines box as we go along.

Problem-focused exam. Documentation of a problem-focused exam has always been relatively easy to recognize; it includes findings from one body area or organ system. The guidelines help here to some extent with the lists of recognized areas and systems.

Expanded problem-focused exam. No changes from what you're used to. Add to the problem-focused exam findings for one system that is related to the problem or symptomatic, and you have an expanded problem-focused exam.

Detailed exam. The words limited and extended, which represent almost the only difference between the definitions of an expanded problem-focused exam and a detailed exam, are still frustratingly undefined:

Since the optional plurals in "area(s)" and "system(s)" imply that more than one system or area may be examined, but that one is enough, you would presumably have a detailed exam if you documented an "extended" examination (whatever that is) of one affected body area and one related organ system. Knowledgeable physicians, however, tend to think of the distinction between expanded problem-focused and detailed exams more in terms of the number of systems examined. According to Barton C. McCann, MD, medical officer in HCFA's Bureau of Policy Development, extended here means both including more systems and performing a more in-depth examination. He says he hopes the distinction between limited and extended can be made more precise and quantifiable in the future. At the moment, though, it's a judgment call, with no clear recourse if your judgment and your carrier's happen to disagree.

Comprehensive exam. One of the new guidelines says that documentation of a general multisystem exam should report findings for at least eight organ systems. This nails down the upper end of the scale fairly well. It also implies that a detailed exam, if reckoned in terms of the number of systems examined, may cover as many as seven. (On the other hand, what constitutes a complete single-system exam remains under discussion.)

The lists of body areas and systems recognized by HCFA are worth some attention, since they are what carriers will use to determine how many systems and body areas you have documented examining. Look closely at the list of systems, in particular; it may not correspond exactly to the list you are used to running through in your mind. For instance, if you are used to documenting as one unit your findings for "HEENT" or even "HEENTN," including the neck as well as head, eyes, ears, nose and throat, note that you are in fact documenting findings for two body parts (head and neck) and two systems (eyes and ears, nose, mouth and throat). Here are other points to keep in mind about the system list:

Note that these last two points together mean that the guidelines recognize 12 systems for the exam where they recognize 14 for the ROS. That may help explain why a general multisystem exam must cover at least eight systems while a complete ROS must cover at least 10. Note, too, that you sometimes have a choice of systems under which to report your findings. For instance, you might report urticaria under the "skin" system or the "hematologic/lymphatic/immunologic" system depending on your clinical judgment and on whether the presenting problem is, say, skin rash or multiple allergies.

The guidelines make several points about what you actually say in the record to document your findings. They can be paraphrased as follows:

While the guidelines say what HCFA would like to see included in your documentation, they don't specify anything about the format. "At every meeting I've gone to, HCFA has said that it's the carrier's responsibility to pull the information out of the chart, not the doctor's to make it easier for the carrier to read," says Charles S. Colodny, MD, a family physician who represents the Academy on the AMA CPT Advisory Committee. That said, however, Colodny adds, "Obviously, it would make more sense to make our charts match what they're looking for. If you type a term paper, you'll probably get a better grade than if you hand write it." Especially given that what your carrier needs to understand your documentation may also help you and your colleagues pull clinically relevant information out of patient charts when you need it later, you might want to do what you easily can to make your charts a reviewer's dream. This is largely a matter of organizing your note to facilitate the reviewer's counting of elements of HPI covered, systems examined, etc. (see "The organized note" and "A template," below).

The exam guidelines are straightforward enough that it's relatively easy to see how the documentation of an exam is likely to score in the eyes of a reviewer. Take the following example -- the objective portions of a SOAP note on a visit with an established male patient complaining of an itchy, red eye:

Nurse's notes:

Age 18, T 99, Wt 135, BP 110/60

O: Eyes:

Erythema of L eye w/ purulent exudate, cobblestoning of L conjunctiva. No hyphema, EOMI both eyes. Fundi nl, no corneal lesions seen.

As a single-system exam, this is clearly problem focused, and the visit is likely to be a 99212 when the rest of the documentation is considered.

For another example, consider this, from a note on a regular follow-up visit with a 50-year-old woman who has insulin-dependent diabetes and coronary artery disease:

Nurse's notes:

Age 50, T 98.6, Wt 156, BP 120/80

O:

Eyes: No retinop
Neck: No nodes, no bruit
Lungs: Clr
CV: S1 and S2 nl, 2/6 SEM, no JVD
Abd: Soft, no organomegaly
Ext: No edema
Skin: No open sores, feet intact
CNS: Nl, no dec sensation


With respect to the diabetes, at least, this note clearly documents an exam that would be considered expanded problem-focused or detailed -- probably the latter. It reports findings from several body areas and six affected or related systems (eyes, hematologic/lymphatic/immunologic, respiratory, cardiovascular, skin and neurologic). Because both the diabetes and CAD are controlled, the findings are almost exclusively relevant negatives.

The trick with the new guidelines, as we've said before, is to keep them in perspective. They are not regulations; they don't require you to do anything, and if you do change the way you document in response to them, it probably won't make a big difference unless you're audited. Nor do they hold you to the highest possible standards: They don't tell you what you should document in any absolute sense; they only tell you what is enough for HCFA. On the other hand, they're not insignificant. If you familiarize yourself with their requirements, you'll have a better idea of what HCFA and other payers expect of you. You will probably have a better idea of what your services are worth and be better able to code with confidence. And who knows, in some cases you may find that not only has HCFA been underpaying you; you've been underbilling HCFA.