Let's Get Physical

Documentation Requirements for Physical Exams

In the already obscure and annoying world of coding and chart auditing, the most obscure and annoying issue of all is documentation for office visits. You struggle to pick the right level E&M code; that's hard enough. But in an audit situation, what matters isn't so much what you coded but what you've documented to support that code.

Unfortunately, I can't make the documentation rules crystal clear to you. You can't elucidate a mess. But I can give you some background and pointers that might make it easier to understand what needs to go in the medical record.

A little history

The backdrop here are the Federal Documentation Guidelines, both the 1995 and the 1997 versions. The 1995 guidelines emphasized the history and exam portions of the encounter and the ability to "count" elements or components.

This caused some discomfort within certain physician specialties. For example, an ophthalmologist will find it difficult to justify ever examining more than one body system - the eyes. No matter how complex the actual service rendered, her E&M coding levels would always be low.

So, the specialty societies asked for revised guidelines that allowed specialists to focus the physical exam within the systems related to their specialties. What resulted were the 1997 guidelines, whose changes were mostly within the physical exam. This version entailed even more "counting," or quantification, of the exam. Although this was what the specialties had asked for, they may not have been prepared for the depth of exam within an organ system required by the newer 1997 version. In fact, the quantification became so pronounced, these guidelines were not adopted to replace the 1995 set, but exist now only as an option; specialists for whom the guidelines are useful can use them, but no one has to.

The question now is what precisely do these exam guidelines call for? What do you need to do to meet the criteria? As if having two systems wasn't confusing enough, many practices have also come to rely on their own little "rules" that have no basis in the formal guidelines at all. Both practitioners and auditors have been forced to interpret somewhat over the last eight to 10 years of operating under the guidelines.

Here is my summary of what the guidelines actually say and what the "rules of thumb" are for actually complying:

Physical Examination Guidelines

The following body areas and organ systems, as listed in the 1995 guidelines, comprise the range of the physical examination.

Body Areas:

• Head, including face
  

• Chest, including breasts and axillae
  

• Neck
  

• Abdomen
  

• Genitalia, groin, buttocks
  

• Back, including spine
  

• Each extremity
  

Organ Systems:

• Constitutional (general appearance, vital signs)
  

• Eyes (pupils equal, round, reactive to light and accommodation; discs; retinal vessels; extraocular movements
  

• Ears, nose, throat (pennae, external auditory canal, tympanic membrane; mucosa, septum, polyps, turbinate; lips, gingiva, posterior pharynx, tonsils, gag reflex)
  

• Cardiovascular (murmur, rub, gallop, hypertension, peripheral vascular pulses, varicose veins)
  

• Respiratory (breath sounds [wheezes, rales, rhonchi], resonance, contour)
  

• Gastrointestinal (Bowel sounds, soft abdominal bruits, ascites, fluid waves)
  

• Genitourinary (Male: penis, scrotum, hydrocele, hernia; Female: external genitalia, Batholin’s glands, cervix, uterus)
  

• Musculoskeletal (range of motion, strength, atrophy, swelling, tenderness, tone)
  

• Skin (cyanosis, pigmentation, turgor, lesions, ulcers, petechiae, purpura)
  

• Neurological (Romberg, tremor, tic, ataxia, aphasia, reflexes)
  

• Psychiatric (alertness, orientation, memory, calculation, abstract concepts, speech, cortical integration)
  

• Hematologic/Immunologic/Lymphatic (blood specimens, immunoassays, lymph nodes).

Rule of thumb:

Any finding or notation, positive or negative, that pertains to one of the systems or areas above is counted as recognition of having examined that system or area. Most providers fail to recognize that even when a system is negative, some payers may look for narrative detail. A body area is generally recognized as having been examined when findings from at least two distinct organ systems are reported in one body area. Each body area counts as one element only of the examination when quantifying the level of physical examination, even if all body areas are inspected. This last item comes from the single-system specialty exam content of the skin and musculoskeletal exams - each somewhat likely to use the body area approach.

There are four types of exams indicated in the levels of E&M codes. Although the descriptors or labels are the same under 1995 and 1997 guidelines, the degree of detail required is different. Let's consider the levels under each set of guidelines.

1995 Guidelines

Problem-focused: a limited examination of the affected body area or organ system. Rule of thumb: one body area or system.

Expanded problem-focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Rule of thumb: two to seven systems (of which one may be a body area).

Detailed: an extended examination of the affected body area(s) or organ system and other symptomatic or related organ system(s). Rule of thumb: two to seven systems (of which one may be a body area) with one organ system likely documented in detail.

Comprehensive: a general multisystem examination or complete examination of a single organ system.

Rule of thumb: eight or more organ systems (of which one may be a body area), or a complete single system examination.

For the expanded problem-focused and detailed exam requirements, many practices have divided the range of two to seven
systems into "safe harbors." For example, they may document two to four systems for the expanded problem-focused exam and five to seven for the detailed exam. This approach is often consistent with the actual exam that either low- or moderate-level decision-making might require. This convention sprung up across the country in about 1996 but has no basis in Federal Guideline authority.

1997 Guidelines

Problem-focused: Perform and document examination of one to five bullet elements in one or more organ systems/body areas from the general multisystem examination, or examination of one to five bullet point elements from one of the 10 single-organ-system examinations, shaded or unshaded boxes.

Expanded problem-focused: Perform and document examination of at least six bullet elements in one or more organ systems from the general multisystem examination, or perform and document examination of at least six bullet point elements from one of the 10 single-organ-system examinations, shaded or unshaded boxes.

Detailed: Perform and document examination of at least six organ systems or body areas, including at least two bullet elements for each organ system or body area from the general multisystem examination, or perform and document examination of at least 12 elements in two or more organ systems or body areas from the general multisystem examination, or perform and document examination of at least 12 bullet elements from one of the single-organ-system examinations, shaded or unshaded boxes. Exception: eye and psychiatric single-system examinations. For these, perform and document at least nine bullet elements, shaded or unshaded boxes.

Comprehensive: perform and document examination of at least nine organ systems or body areas, with all bullet elements for each organ system or body area (unless specific instructions are expected to limit examination content with at least two bullet elements for each organ system or body area) from the general multisystem examination, or perform and document examination of all bullet point elements from one of the 10 single-organ system examinations with documentation of every element in shaded boxes and at least one element in each unshaded box from the single-organ-system examination.

Now how's that for simplifying things! The complexity, breadth, and depth of the 1997 exam criteria is the primary reason this approach was never adopted as the only method to report the physical exam. Although these criteria work well for certain specialists using the single-system specialty exams, some generalists and other specialists do not fare as well using this approach.

Rule of thumb: Check off all the boxes. Seriously, give them what they want. For specialists, an effort is often made to follow the single-system specialty exams and great detail is provided in one or two organ systems. However, these frequently miss one of the elements or other related organ systems and thereby fail to meet single-system exam criteria. For some specialists, it would be easier to follow the 1995 general exam guidelines and simply review eight organ systems. For others, that eighth system is a bit of a stretch. Orthopedics has great difficulty here, for example.

Templates may be used to good effect in the exam area so long as they are used responsibly. Recent review activity has found EMRs and even some paper templates to be overutilized, in that the documentation for the exam gets out of proportion to the nature of the visit. Remember that it is the nature of the visit, problem, or suspected problem that will drive the amount or degree of exam and other encounter elements. If, on review when several patient charts show identical exams - often a full eight to 10 organ systems in great detail, for problems varying from the problem-focused to the truly complex - then the validity of such findings becomes suspect.

We recognize that there are a limited number of physical findings, and only so many ways to report normal findings - but we expect the exam to be in proportion to the nature of the encounter.

Our only hope is to understand the guidelines as well as possible. One can only hope that now that we've had 10 years to practice under the current system, someone will see the wisdom of developing new set of guidelines that is both clear and flexible.

Bill Dacey 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 over 10 years. He can be reached at billdacey@msn.com or via editor@physicianspractice.com.
This article originally appeared in the November/December 2005 issue of Physicians Practice.