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Q: What is the difference between a detailed exam and an expanded problem-focused exam?
A: Unfortunately, there is no straightforward answer to that question. However, the Centers for Medicare & Medicaid Services (CMS) provides some guidance in the 1995 and 1997 Evaluation and Management (E&M) guidelines.
In this case, as in many instances where descriptions are broad, CMS allows Medicare administrative contractors (MACs) to create rules based on their interpretation of the issue. There are a few MACs that offer definitive guidance for determining the difference between an expanded problem-focused exam and a detailed exam.
As of July 1, 2017, National Government Services (NGS) has changed their policy to no longer require 2 to 5 elements for an expanded problem-focused exam and 6 or 7 elements for a detailed exam. They now will audit exams by either 2 to 7 elements or 2 to 5 and 6 to 7 elements, whichever is most beneficial for the provider.
Noridian Medicare interprets the 1995 guidelines for a detailed exam as 5 to 7 body areas and/or organ systems and 12 to 17 bulleted elements for two (or more systems, using the 1997 guidelines).
Palmetto GBA, Novitas Solutions, Cahaba GBA, CGS Administrators, LLC (CGS), Wisconsin Physicians Service (WPS) and First Coast Service Options Inc. (FSCO) all quote CMS 1995 and 1997 guidelines.
So until the rest of the MACs get on board to better define the difference between an expanded problem-focused exam and a detailed exam, or unless your practice happens to be in one of the states in the jurisdictions cited above, the interpretation is left
up to the provider. If not,
I would suggest your office or network create a policy that defines the difference and make sure that all the providers in your practice document the exam according to that definition.