E&M Mixing and Matching

Question: In our office when auditing an E&M service using 1995 guidelines, we consider the EPF (expanded problem-focused exam) to contain between two and four body areas or organ systems and DET (detailed exam) to contain between five and seven body areas or organ systems. I was taught that you can mix and match body areas and organ systems in order to get the level. However, my colleague at my new job was taught that you cannot mix and match them. What is your take on this?

Answer: Often when you hear a payer talking about "mixing and matching" they are talking about mingling 1995 guidelines which are based on organ systems and body areas with the 1997 guidelines which are measured by "element" or "bullets." But I've heard the term refer to the body area/organ system that you mention as well. You are actually posing two questions here. One is about differentiating between EPF and DET by splitting the two-to-seven range into two to four areas/systems and five to seven areas/systems respectively. People do that and it makes a certain kind of sense, but there really is no authoritative precedent for it. Many payers will go so far as to say that you need some number of systems in no great detail, and some degree of detail on one or two of them. That has no overriding authoritative source either - you are hearing different payers giving you their different versions.

The best question for you to answer is whether your documentation is defensible, medically necessary, appropriate, and proportional to the patient's problem(s). There are as many reads on how to measure these things as there are payers.

In answer to your second question, specifically, the CPT says that you can count body areas/organ systems, or mix and match if you will, for PF, EPF, and DET exams. It somewhat notably doesn't mention body areas on the comprehensive exam. Some Medicare payers also specify that the comprehensive exam must contain eight organ systems, and any other areas are additional. The online E&M "Service Guide" tells you that as well. So it's pretty safe to say you can count both, such as two organ systems and a body area for an EPF, or even one of each.

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 billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the May 2011 issue of Physicians Practice.