When working on Medical Billing in a medical practice, there is a lot of protocol that must be followed for the billing to be managed accurately.
One important area is understanding the Four Levels of Medical Examination, as per the 1997 Guidelines determined by the CMS.
The levels of Evaluation and Management services are based on four types of examination:
1) Problem Focused – a limited examination of the affected body area or organ system.
2) Expanded Problem Focused – a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).
3) Detailed – an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
4) Comprehensive – a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).
These types of examinations have been defined for general multi-system and the following single organ systems:
-Cardiovascular
-Ears, Nose, Mouth, and Throat
-Eyes
-Genitourinary (Female or Male)
-Hematologic/Lymphatic/Immunologic
-Musculoskeletal
-Neurological
-Psychiatric
-Respiratory
-Skin
A general multi-system examination or a single organ system examination may be performed by any physician, regardless of specialty.
The type (general multi system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).
For each Level of Exam Performed there are different Document requirements:
Problem Focused: One to five elements identified by a bullet.
Expanded Problem Focused: At least six elements identified by a bullet.
Detailed: At least twelve elements identified by a bullet.
Comprehensive Perform: all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.
