Question: Do I have to document or code my physical examination with all organ systems or can I use just the body areas?
Answer: It all depends on the level of service you are trying to support.
There's an emergency department visit for a patient with a complicated overdose requiring aggressive management to prevent side effects from the ingested materials or a patient with an onset of rapid heart rate requiring IV drug administration and maybe it's a previously healthy young adult patient who is injured in an automobile accident and is brought to the emergency department immobilized and has symptoms compatible with intra-abdominal injuries or multiple extremity injuries.Regardless of the type of presenting problem to the emergency department, the emergency department physician will follow a protocol to determine the extent of the problems presented and what course of intervention is required to help the patient. This medical decision making process shows the complexity of establishing a diagnosis and/or selecting a management option for the cases presented.
Once the level of medical decision-making has been established, the physician will continue in the encounter and try to get some historical information from the patient and then move on to the physical examination.
The physical examination is the objective portion of the encounter and is performed dependent on clinical judgment and on the nature of the presenting problem(s). The level of evaluation and management services recognizes four types of examination that are defined as follows:
Problem Focused: A limited examination of the affected area or organ system.
Expanded Problem Focused: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ system(s).
Comprehensive: A general multi-system examination or complete examination of a single organ system.
As you can see above, there are only four types of examination, but the first three have a combination of either body areas or organ systems. The last type is a comprehensive examination, and, based on the CMS 1995 Documentation Guidelines, the provider must document eight or more of the twelve recognized organ systems.2
This is where the confusion comes in:
- CPT has information that addresses the extent of the examination performed and so does the CMS documentation guidelines.
- In comparison, CMS has twelve recognized organ systems and CPT only has eleven.
- The only organ system that CPT does not have listed is the constitutional system.
- All of the body areas in both the CPT book and the documentation guidelines are the same.
There has been some concern over mixing the body areas and the organ systems or using the body area headings as headings for the organ systems review when performing a comprehensive examination. It is strongly suggested that when a comprehensive examination is being performed, that only the correct verbiage is used to document those findings. You should not use "Abdomen" when documenting/coding your Gastrointestinal organ system or listing just an extremity exam as performing a "musculoskeletal" examination. Check your templates and systems to assure that you are listing the organ systems and not the body areas on those high level accounts.
CMS reviewers and Independent Review Organizations and their teams may try to make it difficult to defend your position on the examination you documented or coded. Therefore, it's better to provide the correct documented than to try and convince an auditor.