I’ve been auditing evaluation & management documentation for a long time and I’ve noticed something about the 1995 exam guidelines that I could really use some help on from a fellow auditor or coder or whomever can help!

I get the overall guidelines are based off of body areas and/or organ systems (for 1995), but what I’m having trouble locating is what information counts within each organ system or body area? For example, my providers put any sort of information if it happens to pertain to their head (body area) or gastrointestinal system (organ system). I’ve directed them that it needs to be quality information and not just anything.

As I have understood it, the 1997 exam bullets are the basis for what each body area or organ system needs to contain. For example: The constitutional organ system bullets are three vital signs and the patient’s general appearance. What I extracted from this is that for a 1995 constitutional exam, it needs three vital signs and/or general appearance to count and not just whatever the provider wants to put.

My MAC here in NM is Novitas, and their online audit tool and their audit score sheet only lists the body areas & organ systems to score a 1995 exam. There aren’t any elements or criteria within each one. Is the listing of a body are and/or organ system all it takes to score a 1995 exam? Is there no criterion for what should be listed within the body area and/or organ system?

I appreciate help and input on this. Thank you!