Auditing Basics: EXAM (aka... touch)

Exam also known as touch

The exam criteria for auditing has 2 different methodologies to choose from. CMS allows us to choose either the 1995 guidelines or the 1997 guidelines to choose from.

Lets explore the 1995 exam guidelines. The 1995 guidelines allow us to recognize either a "body area" or a body "organ system" These are broken down below.

the following body areas are recognized:

• Head, including the face

• Neck

• Chest, including breasts and axillae

• Abdomen

• Genitalia, groin, buttocks

• Back, including spine

• Each extremity

OR
you can choose to utilize body "organ systems" (do not intermix and confuse the two)

the following organ systems are recognized:

•Constitutional (e.g., vital signs, general appearance)
* Ears, nose, mouth and throat
• Cardiovascular
* Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
•Hematologic/lymphatic/immunologic

When utilizing the 95 guidelines for "body systems" or "body areas" to determine the level to be met CMS has outlined the criteria as:

1995 Guidelines = Problem Focused exam is limited to the affected body area or 1 organ system

1995 Guidelines = Expanded Problem Focused exam is to examine the affected body area + other symptomatic or related organ systems for a total of between 2-4 body areas, or organ systems examined

1995 Guidelines = Detailed exam is to examine the affected body area + other symptomatic or related organ systems for a total of between 5-7 body areas, or organ systems examined

1995 Guidelines = Comprehensive exam is to completely examine the affected body area + other symptomatic or related organ systems for a total of 8 or more body areas, or organ systems examined.

Interestingly, the 1995 guidelines published from CMS was a document of aproximately 15 pages, where the 1997 guidelines were closer to 60 pages. So, from that perspective you have more "choices" in the 1997 bullet points, but less confusion with the 1995 exam criterias.

Now.. Let's explore the 1997 examination guidelines or "bullet points" as they are commonly known as. These "bullet's" are encompassed and "bulleted" to make it easier to "count" which areas have been examined. These bullet points have been broken down as a "multi-system" examinination with a comprehensive laundry list of body areas that can be examined, or you can choose to utilize the 1997 "single system" examination bullet points to meet the criteria. The table below outlines the "multi-system" exam bullet points.

1997 Problem Focused = 1-5 elements denoted by a "bullet"

1997 Expanded Problem Focused = 6-11 or more elements denoted by a "bullet"

1997 Detailed = 12-17 elements denoted by a "bullet" OR at least 2 elements identified from six areas/systems

1997 Comprehensive = 18 or more bullets OR all bullets in 9 or more "systems/areas"

**Separate criteria for Single sytem exam - found within the 1997 CMS guidelines (see link)

System/Body Area				Elements of Examination
Constitutional			• Measurement of any three of the following seven
			vital signs: 1) sitting or standing blood pressure,
			2) supine blood pressure, 3) pulse rate and
			regularity, 4) respiration, 5) temperature, 6)
			height, 7) weight (may be measured and recorded)
			• General appearance of patient e.g. development,
			nutrition, body habitus, deformities, attention to
			grooming.
Eyes			• Inspection of conjunctivae and lids.
			• Examination of pupils and irises e.g. reaction to
			light and accommodation, size and symmetry.
			• Ophthalmoscopic examination of optic discs e.g.
			size, C/D ration, appearance and posterior segments
			e.g. vessel changes, exudates, hemorrhages.
Ears, nose,			• External inspection of ears and nose e.g. overall
mouth & throat			appearance, scars, lesions, masses.
			• Otoscopic examination of external auditory canals
			and tympanic membranes.
			• Assessment of hearing e.g. whispered voice,
			finger rub, tuning fork.
			• Inspection of nasal mucosa, septum and turbinate
			• Inspection of lips, teeth, and gums
			• Examination of oropharynx: oral mucosa, salivary
			glands, hard and soft palates, tongue, tonsils and
			posterior pharynx.
Neck			• Examination of neck e.g. masses, overall
			appearance, symmetry, tracheal position, crepitus.
			• Examination of thyroid e.g. enlargement
			tenderness, mass.
Respiratory			• Assessment of respiratory effect e.g. intercostal
			retractions, use of accessory muscles,
			diaphragmatic movement.
			• Percussion of chest e.g. dullness, flatness,
			hyperresonance.
			• Palpation of chest e.g. tactile fremitus
			• Auscultation of lungs e.g. breath sounds,
			adventitious sounds, rubs.
Cardiovascular			• Palpation of heart e.g. location, size, thrills
			• Auscultation of heart with notation of abnormal
			sounds and murmurs.
			Examination of:
			• Carotid arteries e.g. pulse amplitude, bruits.
			• Abdominal aorta e.g. size, bruits
			• Femoral arteries e.g. pulse amplitude, bruits.
			• Pedal pulse e.g. pulse amplitude
			• Extremities for edema and/or varicosities
Chest			• Inspection of breasts e.g. symmetry, nipple
(breasts)			discharge
			• Palpation of breasts and axillae e.g. masses or
			lumps, tenderness.
Gastrointestinal			• Examination of abdomen with notation of
(abdomen)			presence of masses or tenderness.
			• Examination of liver and spleen
			• Examination of presence or absence of hernia.
			• Examination when indicated of anus, perineum
			and rectum, including sphincter tone, presence of
			hemorrhoids, rectal masses.
			• Obtain stool sample for occult blood test when indicated.

Genitourinary			• Examination of the scrotal contents e.g.
(male)			hydrocele, spermatocele, tenderness of cord.
			• Examination of the penis.
			• Digital rectal examination of prostate gland e.g.
			size, symmetry, nodularity, tenderness.
Genitourinary			Pelvic examination (with or without specimen
(female)			collection for smears and cultures) including:
			• Examination of external genitalia e.g. general
			appearance, hair distribution, lesions and vagina
			e.g. general appearance, estrogen effect, discharge,
			lesions, pelvic support, cystocele, rectocele.
			• Examination of the urethra e.g. masses,
			tenderness, scarring.
			• Examination of the bladder e.g. fullness, masses,
			tenderness.
			• Cervix e.g. general appearance, lesions, discharge.
			• Uterus e.g. size, contour, position, mobility,
			tenderness, consistence, descent or support.
			• Adnexa/parametria e.g. masses, tenderness,
			organomegaly, nodularity.
Lymphatic			Palpation of lymph nodes in two or more areas:
			• Neck			• Axillae
			• Groin			• Other
Musculoskeletal			• Examination of gait and station.
			• Inspection and/or palpations of digits and nails
			e.g. clubbing, cyanosis, inflammatory conditions,
			petechiae, ischemia, infections, nodes.
			Examination of joints, bones and muscles of one or
			more of the following six areas 1) head and neck, 2)
			spine, ribs and pelvis, 3) right upper extremity, 4) left
			upper extremity, 5) right lower extremity, 6) left lower
			extremity. The examination of a given area.
			• Inspection and/or palpation with notation of
			presence of any misalignment, asymmetry,
			crepitation, defects, tenderness, masses.
			• Assessment of range of motion with notation of
			any pain, crepitation or contracture.
			• Assessment of stability with notation of any
			dislocation (luxation), subluxation or laxity.
			• Assessment of muscle strength and tone e.g.
			flaccid, cog wheel, spastic with notation of any
			atrophy or abnormal movements.
Skin			• Inspection of skin and subcutaneous tissue e.g.
			rashes, lesions, ulcers.
			• Palpation of skin and subcutaneous tissue e.g.
			induration, subcutaneous nodules, tightening.
Neurologic			• Test cranial nerves with notation of any deficits.
			• Examination of deep tendon reflexes with notation
			of pathological reflexes e.g. Babinski.
			• Examination of sensation e.g. by touch, pin,
			vibration, proprioception.
Psychiatric			• Description of patient's judgment and insight
			Brief assessment of mental status including:
			• Orientation to time, place and person
			• Recent and remote memory
			• Mood and affect e.g. depression, anxiety, agitation.

If you’re still confused regarding exam criteria, please e-mail me or contact me, and I’ll do my best to help!

Auditing Basics - HISTORY!

When dissecting the history component these are required components to be documented:
• "Chief Complaint" (CC)
• "History of Presenting Illness (HPI) OR "Chronic Condition Status" (CCS)
• "Review of Systems" (ROS/ROI
• the patients "Past", "Family", and "Social" history (PFSH)


The Chief Complaint -
Definition: A patient’s chief complaint or purpose for a visit.
The purpose for the medical visit is clearly stated by the patient, and is recorded by the provider of care. The documentation supports that the patient’s perceived needs/expectations and should be addressed during the encounter.

The "History of Presenting Illness (HPI)
Definition: an account obtained during the interview with the patient of the onset, duration, and character of the present illness, as well as of any acts or factors that aggravate or ameliorate the symptoms. The patient is asked what he or she considers to be the cause of the symptoms and whether a similar condition has occurred in the past

OR The "Chronic Condition Status" (CCS)
Definition: a chronic disease is a disease that is long-lasting or recurrent. The term chronic describes the course of the disease, or its rate of onset and development. A chronic course is distinguished from a recurrent course; recurrent diseases relapse repeatedly, with periods of remission in between.

The Review of Systems" (ROS)
Definition: In a health history, a ROS is a system-by-system review of the body functions. The ROS is begun during the initial interview with the patient and completed during the physical examination. As physical findings prompt further questions, providers of care are to outline the systems reviewed and notate if the signs and symptoms are normal, abnormal, or anecdotal.


The "History" of the patient: (PFSH)

Past(Personal) Medical History
A narrative or record of past events and circumstances that are or may be relevant to a patients current state of health. Informally, an account of past diseases, injuries, treatments, and other strictly medical facts. More formally, a comprehensive statement of facts pertaining to past and present health gathered, ideally from the patient, by directed questioning and organized within the medical documentation or chart. This can also be noted as a review of the patients past experiences, including illnesses, injuries, treatments, allergies etc.

•

1.

Past Family History
The family structure and relationships within the family, including information about diseases in family members. The family history provides a ready view of problems or illnesses within the family and inheritance patterns. Study of a trait or disease(s) begins with the affected person and is considered pertinent as the relatives are described. (ie father, mother, siblings, grandparents, aunts, uncles, cousins) At least 3 generations are usually included. Illnesses, hospitalizations, causes of death, miscarriages, abortions, congenital anomalies, and any other unusual features are recorded.

Social History (SH):
A review of the patients past experiences, including illnesses, injuries, treatments, allergies, and may include marital status, past and present occupations, travel, hobbies, stresses, diet, habits, and use of tobacco, alcohol, or drugs

•

1.

Do the Analysis:
In compiling the analysis of the "historical" relevance of the patients history to their current medically presenting illness (HPI) the provider of care will need to carefully consider all facts that are pertinent.

When Auditing the documented history, you cannot "double dip" so to speak, each element has to stand on its own merits.

In identifying the amount of history noted in the record, do not confuse the "review of systems" with "past history" or with the chronic condition status (CCS)


Consider how to put this together within your audit tool to determine the correct level of history that the patient had presented for the provider of care.

These histories do not need to be recorded or re-recorded at every visit, however, the physician or provider DOES need to review the history or historical relevance to the presenting illness and document that they DID REVIEW THE PREVIOUS HISTORY NOTED IN THE CHART. If the patient does reveal more, or un-documented ares of history, the provider should update the record with the additional information.

The Audit Tool: