HEENT Exam/1995 Document guidelines

HEENT
As auditors, we often encounter cases where providers employ language such as HEENT is "normal" or "negative" without clearly noting anything more specifically. This charting technique has caused many auditors to scratch their heads wondering how many body areas and/or organ systems can be credited to the provider when applying the 1995 examination guidelines. In order to be successful, we must first be able to clearly describe the various body areas/organ systems as defined in the 1995 documentation guidelines. To begin, let's break down the HEENT acronym:

H- Head The head is a body area (in the guidelines, it is defined as head, including the face)

E-Ears The ears are a component of ENT. Ears, Nose, Throat constitutes one organ system under 1995 documentation guidelines.

E-Eyes Eyes represent a separate organ system under 1995 documentation guidelines.

N-Nose The nose is yet another component of ENT. Again, Ears, Nose and Throat collectively constitute one organ system under 1995 documentation guidelines.

T- Throat The throat is a component of ENT. Once again, the Ears, Nose, and Throat collectively constitute one organ system under 1995 documentation guidelines. Note: The neck is not included here. The neck represents a separate body area in the 1995 exam guidelines.

So, I think we can all agree that HEENT jointly represents one body area and two organ systems. Per CPT, the following body areas/organ systems are recognized:

Body Areas:
Head, including face Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity

Organ Systems:
Constitutional
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunologic

So now let's get back to the question, how many body areas and/or organ systems can be credited to a provider if the provider simply documents "HEENT is normal"?

We have heard multiple opinions as to the answer to this riddle but we would like to suggest the approach that best mitigates compliance risk and meets the documentation guidelines described by the Centers for Medicare and Medicaid Services (CMS). Essentially, if the provider states that HEENT is "normal" they are indeed referring to one (1) body area and two (2) organ systems.

According to 1995 documentation guidelines, "a brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s)." As an auditor, all we have is what the provider gives us, right? If the provider states "HEENT is normal", they are actually 'on the hook' for examining the Head (Body area), Eyes (Organ system) and ENT (Organ system) and he or she is suggesting they are all normal. We cannot specifically determine whether the provider performed the examination or not because we were not in the examination room at the time of the service. 1997 E&M examination documentation guidelines are much more specific when compared to the 1995 guidelines and require specific documentation of particular elements so much of this discussion is not applicable under 1997 premise. For 1995 guidelines on the other hand, the extent of examination performed is largely dependent on the provider's clinical judgment and their perception of the patient's presenting problem(s). According to CPT®, examinations may range from "limited" to "extended" examinations of single body area/organ system to general multi-system or complete single organ system exams. Clearly, 1995 guidelines provide for more interpretation in terms of what is "limited" or "extended." Certain MACs (e.g., Novitas) provide more clear guidance for documenting and capturing "limited" versus "extended" examinations under 1995 guidelines. Oftentimes, auditors may be perplexed as to what these terms even mean and interpretation is often necessary. Specifically, Novitas directs providers to follow the "4 x 4 methodology" which requires that 4 elements are to be examined in 4 body areas or 4 organ systems in order to qualify for a detailed examination. We suggest ultimately referring to particular payer directives to determine if there are more stringent and restrictive policies in place.

According to various posts including the AAPC on-line forum, two (2) organ systems can be credited when providers simply state "HEENT is normal". In theory this is true but we suggest using education as the basis to assist providers in documenting the body areas/organ systems more distinctly. For example, he/she may choose to capture this information in a slightly different manner via written, typed, dictated or macro/template form as illustrated below:





By documenting in the above manner, there leaves no doubt as to the number of organ systems actually examined and creates a much more defensible medical record entry in the event provider's charting techniques are called into question or a post-payment review ensues. When a provider clearly documents the individual components of HEENT rather than claiming that the whole is "normal" it becomes very clear what body areas and organ systems have been addressed. The best offense is a strong defense and this solution is quite simple to implement.