Urology Coding Alert : Avoid The Pressure Of Choosing Physical Examination Levels

By Author: Leesa Israel
Total Articles: 4
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1995 vs. 1997 guidelines: Choose one per claim, but you should feel free to use either one for different claims.


Determining the Physical Examination Level


There are two sets of guidelines you should know before determining the level of the physical examination key element for your E/M coding: 1995 and 1997 guidelines.


Both sets of guidelines help you decide which of the following listed four levels of examinations your urologist accomplished during an E/M service:
problem-focused,
detailed,
expanded problem focused,
and comprehensive.
The level of exam is a key factor in determining which code you should report: 99201- 99205 (Office or other outpatient visit for the E/M of a new patient, which needs these 3 basic components …) for new patients or 99212-99215 (Office or other outpatient visit for the E/M of an established patient, which requires at least 2 of these 3 basic components …) for established patients.


1995 and 1997 Guidelines: What's the Difference


The most significant ...
... difference between these two sets of guidelines is the exam element.


1997: The 1997 guidelines involve specific physical exam elements that must be addressed in the documentation. If a physician addresses elements other than those specified in the guidelines, the physician will not essentially receive credit for that particular element in the level of service. Also, if the language relating to an exam element included in the documentation is different from the one in the guidelines, an auditor who has not had much clinical experience may reject the element from being credited in the level of service.


1995: The 1995 guidelines are comparatively less restrictive. They let the physician make any comment in any of the designated body areas and/or organ systems he examines. What the physician examines within the areas and systems and the language he or she chooses to document are eventually decided by the physician.


Which Guidelines Should You Use?


It is not required that you pick one set of guidelines and stick with them whenevr you code an E/M service. You can switch between 1995 and 1997 and choose whichever set of guidelines is most beneficial for each encounter.


Important: The key, however, is that, for a single encounter you should use either 1995 or 1997 guidelines. Keep in mind that the guidelines are only for the reporting of the physical examination. The remaining two key components, history and medical decision making, continue to be the same. It doesn't matter which physical examination guidelines you use.


Besides, practices should know if there are any special requirements of their contracts with their insurers.


So which guideline should you use? That also depends on your urologist and how does he document. Usually the 1995 documentation guidelines are going to be more beneficial for most practices. The reason being that they are more flexible and they also reflect the way most physicians were trained to document. However, some physicians may have been trained or may have developed decent documentation practices around the 1997 guidelines, and this may be beneficial to them.


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