Exam Guidelines

The Hospitalist. 2011 November;2011(11):

November 1, 2011 | The Hospitalist

Determining Levels of Exam

A reviewer assigns one of four exam levels. As with the history component, documentation must meet the requirements for a particular level of exam before assigning it to any visit category (see Table 1). The requirements vary greatly between the 1995 and 1997 guidelines. The four recognized levels of history are problem-focused, expanded problem-focused, detailed, and comprehensive (see Table 2A and 2B). Similar to the history component, a few visit categories do not have associated exam levels or documentation requirements for exam elements, such as critical care and discharge day management.

As counting the number of exam elements seems rather straightforward, the most problematic feature of the 1995 guidelines involves “detailed” exam description. Overlap exists between the “detailed” and “expanded problem-focused” exam requirements. Both call for the notation of 2-7 systems/areas, but the detailed exam requires an “extended exam of the affected system/area related to the presenting problem.” Without further guidance from CMS, inconsistency flourishes. Documentation, review, and audit of the detailed exam become arbitrary.

Consider this cardiovascular exam example: “regular rate and rhythm; normal S1, S2; no jugular venous distention; no murmur, gallop or rub; peripheral pulses intact; no edema noted. Lungs clear.” Assigned credit is subject to clinical inference. Although most Medicare contractors attempt to avoid confusion and default to the 1997 requirements for a detailed exam, others attempt to define it.³ Highmark Medicare Services has uniquely developed the 4x4 tool (detailed exam=documentation of four elements examined in four body areas or four organ systems) in hopes of proper and consistent implementation of the evaluation and management (E/M) guidelines.⁴