I am the assistant director of compliance for University of Washington Physicians. I am concerned because the exam requirements listed in “Coding Level-IV Visits Without Fear” [February 2006] do not match Medicare’s 1997 Documentation Guidelines for Evaluation and Management Services. The article states that the 1997 detailed exam requirements can be met by “examination of affected body area and at least four other symptomatic-related organ systems.” This recommendation meets neither 1997 nor 1995 documentation guidelines. It is difficult to communicate documentation guidelines and even further complicated when publications do not match regulatory guidance.

Author’s response:

I developed the worksheet on which the article focuses to help myself understand and code level-IV visits properly. Several of my colleagues asked for a copy, and soon it was in use by many in our clinic. Because of its simplicity and usefulness, I decided to publish it so others could also benefit. A few suggestions from readers are being added to the online version of the worksheet to clarify certain components. I developed both the article and worksheet using the 1995 guidelines, but somewhere in the process, this was incorrectly changed to 1997.

The 1995 guidelines state that a level-IV evaluation and management service is based on a detailed exam, defined as “an extended examination of the affected body area(s) and other symptomatic or related organ system(s).” The exact number of body areas or organ systems required is not stated, except in reference to a comprehensive exam, which “should include findings about 8 or more of the 12 organ systems.” Due to this documentation guideline, the detailed exam has historically been defined as five to seven body areas or organ systems, and that is currently our clinic’s coding practice.

The 1997 guidelines require more detail, but, thankfully, we are given the option of using either one. The purpose of the worksheet was to keep it simple, and the 1995 guidelines are the easiest to fulfill.

Editor’s note:

The online version of this article has been updated to correctly cite the 1995 guidelines as the source for its worksheet. Dr. Waller’s interpretation of the 1995 guidelines is not uncommon, and it echoes a previous discussion in the pages of FPM (see the footnote to “How to Get All the 99214s You Deserve,” October 2003). Many coding instructors teach that under the 1995 documentation guidelines an expanded problem focused exam involves two to four organ systems and a detailed exam involves five to seven organ systems. Many also teach that under the 1995 and 1997 versions of the guidelines physicians can fulfill the extended history of the present illness (HPI) requirements by including either four or more elements of the HPI or the status of three or more chronic conditions. Staff from the Centers for Medicare & Medicaid Services (CMS, formerly the Health Care Financing Administration) announced these changes in a public forum in 1996 and indicated that the 1995 guidelines would be modified to incorporate them. Unfortunately, CMS never published the changes.

Consequently, the 1995 version of the documentation guidelines makes no distinction between expanded problem focused and detailed exams in terms of organ systems/body areas; each may involve two to seven. The only distinction in the guidelines is that an expanded problem-focused exam is “limited” and a detailed exam is “extended.” The 1995 guidelines also do not incorporate the “3+ chronic disease” rule in the definition of HPI, although the 1997 guidelines do.