New changes to E/M service may clear up the confusion.
Under the current 1995 Documentation Guidelines for Evaluation and Management (E/M) Services, 2-7 body parts and/or organ systems are examined for both the expanded problem-focused visit and detailed physical exam visit.
Effective for dates of service on or after July 1, 2017, (and applicable only to claims submitted to NGS) a detailed exam involves 6-7 body areas or organ systems, and an expanded problem-focused exam involves 2-5 body areas or organ systems.
Now maybe it is the perfect time to institute training and education to providers and coding staff regarding the new change to one of the key components of E/M services. Training may also include:
- A diligent approach toward quality examination documentation;
- Coding and documentation compliance issues for upcoding and downcoding;
- How the physical examination section should always align with the history of present illness section and care plan area of the note, with medical necessity clearly detailed.
This one small change makes educating providers on how to select a level of service a much more approachable learning opportunity.