Physicians only should perform patient examinations based upon the presenting problem and the standard of care. As mentioned in my previous column (April 2008, p. 21), the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) set forth two sets of documentation guidelines. The biggest difference between them is the exam component.
The 1995 guidelines distinguish 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).
Further, these guidelines let physicians document their findings in any manner while adhering to some simple rules:
- Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems; and
- Elaborate on abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.
The 1997 guidelines comprise bulleted items—referred to as elements—that correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.
For example, the physician only receives credit for documentation of vital signs (an element of the constitutional system) when three measurements are referenced (e.g., blood pressure, heart rate, and respiratory rate). Documentation that does not include three measurements or only contains a single generalized comment (e.g., vital signs stable) cannot be credited to the physician in the 1997 guidelines—even though these same comments are credited when applying the 1995 guidelines.
This logic also applies to the lymphatic system. The physician must identify findings associated with at least two lymphatic areas examined (e.g., “no lymphadenopathy of the neck or axillae”).
Elements that do not contain numeric criterion but identify multiple components require documentation of at least one component. For example, one psychiatric element involves the assessment of the patient’s “mood and affect.” If the physician comments that the patient appears depressed but does not comment on a flat (or normal) affect, the physician still receives credit for this exam element.