Documentation
Guidelines for Evaluation and Management Services
American Medical Association
Health Care Financing Administration
May, 1997
Table of Contents
Foreword
Introduction
What Is Documentation and
Why Is it Important?
What Do Payers Want and Why?
General Principles of
Medical Record Documentation
Documentation of E/M Services
Documentation of History
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family and/or Social History
(PFSH)
Documentation of Examination
General Multi-System Examinations
Single Organ System Examinations
Content and Documentation
Requirements
General Multi-System Examination
Cardiovascular Examination
Ear, Nose and Throat Examination
Eye Examination
Genitourinary Examination
Hematologic/Lymphatic/Immunologic
Examination
Musculoskeletal Examination
Neurological Examination
Psychiatric Examination
Respiratory Examination
Skin Examination
Documentation of
the Complexity of Medical Decision Making
Number of Diagnoses or Management
Options
Amount and/or Complexity of
Data to Be Reviewed
Risk of
Significant Complications, Morbidity, and/or Mortality
Table of Risk
Documentation
of an Encounter Dominated by Counseling or Coordination of Care
FOREWORD 
These guidelines have been developed jointly by the American Medical Association (AMA)
and the Health Care Financing Administration (HCFA). Our mutual goal is to provide
physicians and claims reviewers with advice about preparing or reviewing documentation for
Evaluation and Management services. In developing and testing the validity of these
guidelines, special emphasis was placed on assuring that they:
- are consistent with the clinical descriptors and definitions contained in CPT,
- would be widely accepted by clinicians and minimize any changes in record-keeping
practices, and
- would be interpreted and applied uniformly by users across the country.
This edition contains a substantial amount of new material and a number of significant
revisions in material that appeared in the first edition. Because of the extensive
changes, the section on examination which
begins on page 10 should be read in its entirety. In this edition:
- The content of general multi-system examinations has been defined with greater clinical
specificity.
- Documentation requirements for general multi-system examinations have been changed.
- For the first time, content and documentation requirements have been defined for
examinations pertaining to ten organ systems. The content of these examinations was
developed with the assistance of representatives from the specialties that frequently
perform these examinations.
- Several editorial changes have been made in the definitions of the four types of examinations at the top of page
10. This text also appears in CPT itself in the section headed "Evaluation and
Management (E/M) Services Guidelines," but the revisions will not appear there until
the 1999 edition of CPT.
- The definition of an extended history of present illness on
page 7 has been expanded to include information about chronic or inactive conditions.
The AMA and HCFA wish to thank the CPT Editorial Panel, the CPT Advisory Committees,
the Practicing Physicians Advisory Council, and the Medicare Contractor Medical Directors
for their thoughtful advice, comments and direction concerning the many complex issues
that were addressed in the development of these guidelines. The AMA and HCFA are committed
to continually improving these guidelines and welcome comments based on their usage.
I. INTRODUCTION
WHAT IS DOCUMENTATION
AND WHY IS IT IMPORTANT?
Medical record documentation is required to record pertinent facts, findings, and
observations about an individual's health history including past and present illnesses,
examinations, tests, treatments, and outcomes. The medical record chronologically
documents the care of the patient and is an important element contributing to high quality
care. The medical record facilitates:
- the ability of the physician and other health care professionals to evaluate and plan
the patient's immediate treatment, and to monitor his/her health care over time.
- communication and continuity of care among physicians and other health care
professionals involved in the patient's care;
- accurate and timely claims review and payment;
- appropriate utilization review and quality of care evaluations; and
- collection of data that may be useful for research and education.
An appropriately documented medical record can reduce many of the "hassles"
associated with claims processing and may serve as a legal document to verify the care
provided, if necessary.
WHAT DO PAYERS WANT AND WHY?
Because payers have a contractual obligation to enrollees, they may require reasonable
documentation that services are consistent with the insurance coverage provided. They may
request information to validate:
- the site of service;
- the medical necessity and appropriateness of the diagnostic and/or therapeutic services
provided; and/or
- that services provided have been accurately reported.
II. GENERAL
PRINCIPLES OF MEDICAL RECORD DOCUMENTATION
The principles of documentation listed below are applicable to all types of medical and
surgical services in all settings. For Evaluation and Management (E/M) services, the
nature and amount of physician work and documentation varies by type of service, place of
service and the patient's status. The general principles listed below may be modified to
account for these variable circumstances in providing E/M services.
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:
- reason for the encounter and relevant history, physical examination findings and prior
diagnostic test results;
- assessment, clinical impression or diagnosis;
- plan for care; and
- date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary
services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating and/or consulting
physician.
5. Appropriate health risk factors should be identified.
6. The patient's progress, response to and changes in treatment, and revision of
diagnosis should be documented.
7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing
statement should be supported by the documentation in the medical record.
III. DOCUMENTATION OF E/M SERVICES
This publication provides definitions and documentation guidelines for the three key
components of E/M services and for visits which consist predominately of counseling or
coordination of care. The three key components--history,
examination, and medical decision making--appear in the descriptors for office and other
outpatient services, hospital observation services, hospital inpatient services,
consultations, emergency department services, nursing facility services, domiciliary care
services, and home services. While some of the text of CPT has been repeated in this
publication, the reader should refer to CPT for the complete descriptors for E/M services
and instructions for selecting a level of service. Documentation guidelines are identified
by the symbol •DG.
The descriptors for the levels of E/M services recognize seven components which are
used in defining the levels of E/M services. These components are:
- history;
- examination;
- medical decision making;
- counseling;
- coordination of care;
- nature of presenting problem; and
- time.
The first three of these components (i.e., history, examination and medical decision
making) are the key components in selecting the level of E/M services. In the case of
visits which consist predominantly of counseling or coordination of care, time is
the key or controlling factor to qualify for a particular level of E/M service.
Because the level of E/M service is dependent on two or three key components,
performance and documentation of one component (eg, examination) at the highest level does
not necessarily mean that the encounter in its entirety qualifies for the highest level of
E/M service.
These Documentation Guidelines for E/M services reflect the needs of the typical adult
population. For certain groups of patients, the recorded information may vary slightly
from that described here. Specifically, the medical records of infants, children,
adolescents and pregnant women may have additional or modified information recorded in
each history and examination area.
As an example, newborn records may include under history of the present illness (HPI)
the details of mother's pregnancy and the infant's status at birth; social history will
focus on family structure; family history will focus on congenital anomalies and
hereditary disorders in the family. In addition, the content of a pediatric examination
will vary with the age and development of the child. Although not specifically defined in
these documentation guidelines, these patient group variations on history and examination
are appropriate.
A. DOCUMENTATION OF HISTORY
The levels of E/M services are based on four types of history (Problem Focused,
Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some
or all of the following elements:
- Chief complaint (CC);
- History of present illness (HPI);
- Review of systems (ROS); and
- Past, family and/or social history (PFSH).
The extent of history of present illness, review of systems and past, family and/or
social history that is obtained and documented is dependent upon clinical judgement and
the nature of the presenting problem(s).
The chart below shows the progression of the elements required for each type of
history. To qualify for a given type of history all three elements in the table
must be met. (A chief complaint is indicated at all levels.)
| History of Present Illness (HPI) |
Review of Systems (ROS) |
Past, Family, and/or Social History (PFSH) |
Type of History |
| Brief |
N/A |
N/A |
Problem Focused |
| Brief |
Problem Pertinent |
N/A |
Expanded Problem Focused |
| Extended |
Extended |
Pertinent |
Detailed |
| Extended |
Complete |
Complete |
Comprehensive |
DG: The CC, ROS and PFSH may be listed as separate elements of
history, or they may be included in the description of the history of the present illness.
DG: A ROS and/or a PFSH obtained during an earlier encounter does
not need to be re-recorded if there is evidence that the physician reviewed and updated
the previous information. This may occur when a physician updates his or her own record or
in an institutional setting or group practice where many physicians use a common record.
The review and update may be documented by:
1) describing any new ROS and/or PFSH information or noting there has been no
change in the information; and
2) noting the date and location of the earlier ROS and/or PFSH.
DG: The ROS and/or PFSH may be recorded by ancillary staff or on a
form completed by the patient. To document that the physician reviewed the information,
there must be a notation supplementing or confirming the information recorded by others.
DG: If the physician is unable to obtain a history from the
patient or other source, the record should describe the patient's condition or other
circumstance which precludes obtaining a history.
Definitions and specific documentation guidelines for each of the elements of history
are listed below.
CHIEF COMPLAINT (CC )
The CC is a concise statement describing the symptom, problem, condition, diagnosis,
physician recommended return, or other factor that is the reason for the encounter,
usually stated in the patient's words.
DG: The medical record should clearly reflect the chief complaint.
HISTORY OF PRESENT ILLNESS (HPI)
The HPI is a chronological description of the development of the patient's present
illness from the first sign and/or symptom or from the previous encounter to the present.
It includes the following elements:
- location,
- quality,
- severity,
- duration,
- timing,
- context,
- modifying factors, and
- associated signs and symptoms.
Brief and extended HPIs are
distinguished by the amount of detail needed to accurately characterize the clinical
problem(s).
A brief HPI consists of one to three elements of the HPI.
DG: The medical record should describe one to three elements of
the present illness (HPI).
An extended HPI consists of at
least four elements of the HPI or the status of at least three chronic or inactive
conditions.
DG: The medical record should describe at least four elements of
the present illness (HPI), or the status of at least three chronic or inactive conditions.
REVIEW OF SYSTEMS (ROS)
A ROS is an inventory of body systems obtained through a series of questions seeking to
identify signs and/or symptoms which the patient may be experiencing or has experienced.
For purposes of ROS, the following systems are recognized:
- Constitutional symptoms (e.g., fever, weight loss)
- Eyes
- Ears, Nose, Mouth, Throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurological
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
A problem pertinent ROS inquires about the system directly
related to the problem(s) identified in the HPI.
DG: The patient's positive responses and pertinent negatives for
the system related to the problem should be documented.
An extended ROS inquires about the system directly related to
the problem(s) identified in the HPI and a limited number of additional systems.
DG: The patient's positive responses and pertinent negatives for two
to nine systems should be documented.
A complete ROS inquires about the system(s) directly related
to the problem(s) identified in the HPI plus all additional body
systems.
DG: At least ten organ systems must be reviewed.
Those systems with positive or pertinent negative responses must be individually
documented. For the remaining systems, a notation indicating all other systems are
negative is permissible. In the absence of such a notation, at least ten systems must be
individually documented.
PAST, FAMILY AND/OR
SOCIAL HISTORY (PFSH)
The PFSH consists of a review of three areas:
- past history (the patient's past experiences with illnesses, operations, injuries and
treatments);
- family history (a review of medical events in the patient's family, including diseases
which may be hereditary or place the patient at risk); and
- social history (an age appropriate review of past and current activities).
For certain categories of E/M services that include only an interval history, it is not
necessary to record information about the PFSH. Those categories are subsequent hospital
care, follow-up inpatient consultations and subsequent nursing facility care.
A pertinent PFSH is a review of the history area(s) directly
related to the problem(s) identified in the HPI.
DG: At least one specific item from any of the
three history areas must be documented for a pertinent PFSH .
A complete PFSH is of a review of two or all three of the
PFSH history areas, depending on the category of the E/M service. A review of all three
history areas is required for services that by their nature include a comprehensive
assessment or reassessment of the patient. A review of two of the three history areas is
sufficient for other services.
DG: At least one specific item from two of the
three history areas must be documented for a complete PFSH for the following categories of
E/M services: office or other outpatient services, established patient; emergency
department; domiciliary care, established patient; and home care, established patient.
DG: At least one specific item from each of the
three history areas must be documented for a complete PFSH for the following categories of
E/M services: office or other outpatient services, new patient; hospital observation
services; hospital inpatient services, initial care; consultations; comprehensive nursing
facility assessments; domiciliary care, new patient; and home care, new patient.
B. DOCUMENTATION OF EXAMINATION
The levels of E/M services are based on four types of examination:
- Problem Focused -- a limited examination of the affected body
area or organ system.
- 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).
- 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).
- 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)
- Genitourinary (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 judgement, the patient's history, and the nature of the
presenting problem(s).
The content and documentation requirements for each type and level of examination are
summarized below and described in detail in tables beginning on page 13. In the tables, organ systems
and body areas recognized by CPT for purposes of describing examinations are shown in the
left column. The content, or individual elements, of the examination pertaining to that
body area or organ system are identified by bullets (•) in the right column.
Parenthetical examples, "(eg, ...)", have been used for clarification and to
provide guidance regarding documentation. Documentation for each element must satisfy any
numeric requirements (such as "Measurement of any three of the following seven...")
included in the description of the element. Elements with multiple components but with no
specific numeric requirement (such as "Examination of liver and spleen")
require documentation of at least one component. It is possible for a given examination to
be expanded beyond what is defined here. When that occurs, findings related to the
additional systems and/or areas should be documented.
DG: Specific abnormal and relevant negative findings of the
examination of the affected or symptomatic body area(s) or organ system(s) should be
documented. A notation of "abnormal" without elaboration is insufficient.
DG: Abnormal or unexpected findings of the examination of any
asymptomatic body area(s) or organ system(s) should be described.
DG: 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).
GENERAL MULTI-SYSTEM
EXAMINATIONS
General multi-system examinations are described in detail beginning on page 13. To qualify for a given level of
multi-system examination, the following content and documentation requirements should be
met:
- Problem Focused Examination-should include performance and
documentation of one to five elements identified by a bullet (•) in
one or more organ system(s) or body area(s).
- Expanded Problem Focused Examination-should include
performance and documentation of at least six elements identified by a
bullet (•) in one or more organ system(s) or body area(s).
- Detailed Examination--should include at least six
organ systems or body areas. For each system/area selected, performance and
documentation of at least two elements identified by a bullet (•) is
expected. Alternatively, a detailed examination may include performance and documentation
of at least twelve elements identified by a bullet (•) in two or
more organ systems or body areas.
- Comprehensive Examination--should include at least
nine organ systems or body areas. For each system/area selected, all
elements of the examination identified by a bullet (•) should be performed,
unless specific directions limit the content of the examination. For each area/system,
documentation of at least two elements identified by a bullet is
expected.
SINGLE ORGAN SYSTEM EXAMINATIONS
The single organ system examinations recognized by CPT are described in detail
beginning on page 18. Variations among these examinations in the organ systems and body
areas identified in the left columns and in the elements of the examinations described in
the right columns reflect differing emphases among specialties. To qualify for a given
level of single organ system examination, the following content and documentation
requirements should be met:
- Problem Focused Examination--should include performance and
documentation of one to five elements identified by a bullet (•),
whether in a shaded or unshaded box.
- Expanded Problem Focused Examination--should include
performance and documentation of at least six elements identified by a
bullet (•), whether in a shaded or unshaded box.
- Detailed Examination--examinations other than the eye and
psychiatric examinations should include performance and documentation of at least
twelve elements identified by a bullet (•), whether in shaded or unshaded
box.
Eye and psychiatric examinations should include the
performance and documentation of at least nine elements identified by a bullet (•),
whether in a shaded or unshaded box.
- Comprehensive Examination--should include performance of all
elements identified by a bullet (•), whether in a shaded or unshaded box.
Documentation of every element in a box with a shaded border and at least one
element in a box with an unshaded border is expected.
CONTENT AND DOCUMENTATION
REQUIREMENTS
General Multi-System Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Eyes |
- Inspection of conjunctivae and lids
- Examination of pupils and irises (eg, reaction to light and
accommodation, size and symmetry)
- Ophthalmoscopic examination of optic discs (eg, size, C/D ratio,
appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
|
| Ears, Nose, Mouth and Throat |
- External inspection of ears and nose (eg, overall appearance, scars,
lesions, masses)
- Otoscopic examination of external auditory canals and tympanic membranes
- Assessment of hearing (eg, whispered voice, finger rub, tuning fork)
- Inspection of nasal mucosa, septum and turbinates
- 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 (eg, masses, overall appearance, symmetry, tracheal
position, crepitus)
- Examination of thyroid (eg, enlargement, tenderness, mass)
|
| Respiratory |
- Assessment of respiratory effort (eg, intercostal retractions, use of
accessory muscles, diaphragmatic movement)
- Percussion of chest (eg, dullness, flatness, hyperresonance)
- Palpation of chest (eg, tactile fremitus)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
|
| Cardiovascular |
- Palpation of heart (eg, location, size, thrills)
- Auscultation of heart with notation of abnormal sounds and murmurs
Examination of:
- carotid arteries (eg, pulse amplitude, bruits)
- abdominal aorta (eg, size, bruits)
- femoral arteries (eg, pulse amplitude, bruits)
- pedal pulses (eg, pulse amplitude)
- extremities for edema and/or varicosities
|
| Chest (Breasts) |
- Inspection of breasts (eg, symmetry, nipple discharge)
- Palpation of breasts and axillae (eg, masses or lumps, tenderness)
|
| Gastrointestinal (Abdomen) |
- Examination of abdomen with notation of presence of masses or tenderness
- Examination of liver and spleen
- Examination for presence or absence of hernia
- Examination of anus, perineum and rectum, including sphincter tone,
presence of hemorrhoids, rectal masses
- Obtain stool sample for occult blood test when indicated
|
| Genitourinary |
MALE:
- Examination of the scrotal contents (eg, hydrocele, spermatocele,
tenderness of cord, testicular mass)
- Examination of the penis
- Digital rectal examination of prostate gland (eg, size, symmetry,
nodularity, tenderness)
|
| |
FEMALE:
Pelvic examination (with or without specimen collection for smears and
cultures), including
- Examination of external genitalia (eg, general appearance, hair
distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge,
lesions, pelvic support, cystocele, rectocele)
- Examination of urethra (eg, masses, tenderness, scarring)
- Examination of bladder (eg, fullness, masses, tenderness)
- Cervix (eg, general appearance, lesions, discharge)
- Uterus (eg, size, contour, position, mobility, tenderness, consistency,
descent or support)
- Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
|
| Lymphatic |
Palpation of lymph nodes in two or
more areas:
|
| Musculoskeletal |
- Examination of gait and station
- Inspection and/or palpation of digits and nails (eg, 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; and 6) left lower extremity.
The examination of a given area includes:
- Inspection and/or palpation with notation of presence of any
misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
- 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 (eg, flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements
|
| Skin |
- Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
- Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous
nodules, tightening)
|
| Neurologic |
- Test cranial nerves with notation of any deficits
- Examination of deep tendon reflexes with notation of pathological
reflexes (eg, Babinski)
- Examination of sensation (eg, 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 (eg, depression, anxiety, agitation)
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| Problem Focused |
One to five elements
identified by a bullet.
|
| Expanded Problem Focused |
At least six elements
identified by a bullet.
|
| Detailed |
At least two elements
identified by a bullet from each of six areas/systems
OR at least twelve elements identified by a bullet in two or more
areas/systems.
|
| Comprehensive |
Perform all elements
identified by a bullet in at least nine organ systems or body areas and
document at least two elements identified by a bullet from each
of nine areas/systems.
|
Cardiovascular Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
|
| Eyes |
- Inspection of conjunctivae and lids (eg, xanthelasma)
|
| Ears, Nose, Mouth and Throat |
- Inspection of teeth, gums and palate
- Inspection of oral mucosa with notation of presence of pallor or cyanosis
|
| Neck |
- Examination of jugular veins (eg, distension; a, v or cannon a waves)
- Examination of thyroid (eg, enlargement, tenderness, mass)
|
| Respiratory |
- Assessment of respiratory effort (eg, intercostal retractions, use of
accessory muscles, diaphragmatic movement)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
|
| Cardiovascular |
- Palpation of heart (eg, location, size and forcefulness of the point of
maximal impact; thrills; lifts; palpable S3 or S4)
- Auscultation of heart including sounds, abnormal sounds and murmurs
- Measurement of blood pressure in two or more extremities when indicated
(eg, aortic dissection, coarctation)
Examination of:
- Carotid arteries (eg, waveform, pulse amplitude, bruits, apical-carotid
delay)
- Abdominal aorta (eg, size, bruits)
- Femoral arteries (eg, pulse amplitude, bruits)
- Pedal pulses (eg, pulse amplitude)
- Extremities for peripheral edema and/or varicosities
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
- examination of abdomen with notation of presence of masses or tenderness
- Examination of liver and spleen
- Obtain stool sample for occult blood from patients who are being
considered for thrombolytic or anticoagulant therapy
|
| Genitourinary (Abdomen) |
|
| Lymphatic |
|
| Musculoskeletal |
- Examination of the back with notation of kyphosis or scoliosis
- Examination of gait with notation of ability to undergo exercise testing
and/or participation in exercise programs
- Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic)
with notation of any atrophy and abnormal movements
|
| Extremities |
- Inspection and palpation of digits and nails (eg, clubbing, cyanosis,
inflammation, petechiae, ischemia, infections, Osler's nodes)
|
| Skin |
- Inspection and/or palpation of skin and subcutaneous tissue (eg, stasis
dermatitis, ulcers, scars, xanthomas)
|
| Neurological/Psychiatric |
Brief assessment of mental
status including
- Orientation to time, place and person,
- Mood and affect (eg, depression, anxiety, agitation)
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
Ear, Nose and Throat Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
- Assessment of ability to communicate (eg, use of sign language or other
communication aids) and quality of voice
|
| Head and Face |
- Inspection of head and face (eg, overall appearance, scars, lesions and
masses)
- Palpation and/or percussion of face with notation of presence or absence
of sinus tenderness
- Examination of salivary glands
- Assessment of facial strength
|
| Eyes |
- Test ocular motility including primary gaze alignment
|
| Ears, Nose, Mouth and Throat |
- Otoscopic examination of external auditory canals and tympanic membranes
including pneumo-otoscopy with notation of mobility of membranes
- Assessment of hearing with tuning forks and clinical speech reception
thresholds (eg, whispered voice, finger rub)
- External inspection of ears and nose (eg, overall appearance, scars,
lesions and masses)
- Inspection of nasal mucosa, septum and turbinates
- Inspection of lips, teeth and gums
- Examination of oropharynx: oral mucosa, hard and soft palates, tongue,
tonsils and posterior pharynx (eg, asymmetry, lesions, hydration of mucosal surfaces)
- Inspection of pharyngeal walls and pyriform sinuses (eg, pooling of
saliva, asymmetry, lesions)
- Examination by mirror of larynx including the condition of the
epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not
required in children)
- Examination by mirror of nasopharynx including appearance of the mucosa,
adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children)
|
| Neck |
- Examination of neck (eg, masses, overall appearance, symmetry, tracheal
position, crepitus)
- Examination of thyroid (eg, enlargement, tenderness, mass)
|
| Respiratory |
- Inspection of chest including symmetry, expansion and/or assessment of
respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic
movement)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
|
| Cardiovascular |
- Auscultation of heart with notation of abnormal sounds and murmurs
- Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
|
| Genitourinary |
|
| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
|
| Musculoskeletal |
|
| Extremities |
|
| Skin |
|
| Neurological/Psychiatric |
- Test cranial nerves with notation of any deficits
Brief assessment of mental status including
- Orientation to time, place and person,
- Mood and affect (eg, depression, anxiety, agitation)
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
Eye Examination
System/Body Area |
Elements of Examination |
| Constitutional |
|
| Head and Face |
|
| Eyes |
- Test visual acuity (Does not include determination of refractive error)
- Gross visual field testing by confrontation
- Test ocular motility including primary gaze alignment
- Inspection of bulbar and palpebral conjunctivae
- Examination of ocular adnexae including lids (eg, ptosis or
lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes
- Examination of pupils and irises including shape, direct and consensual
reaction (afferent pupil), size (eg, anisocoria) and morphology
- Slit lamp examination of the corneas including epithelium, stroma,
endothelium, and tear film
- Slit lamp examination of the anterior chambers including depth, cells,
and flare
- Slit lamp examination of the lenses including clarity, anterior and
posterior capsule, cortex, and nucleus
- Measurement of intraocular pressures (except in children and patients
with trauma or infectious disease)
Ophthalmoscopic examination through dilated pupils (unless
contraindicated) of
- Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping,
tumor elevation) and nerve fiber layer
- Posterior segments including retina and vessels (eg, exudates and
|
| Ears, Nose, Mouth and Throat |
|
| Neck |
|
| Respiratory |
|
| Cardiovascular |
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
|
| Genitourinary |
|
| Lymphatic |
|
| Musculoskeletal |
|
| Extremities |
|
| Skin |
|
| Neurological/ Psychiatric |
Brief assessment of mental status including
- Orientation to time, place and person
- Mood and affect (eg, depression, anxiety, agitation)
|
| |
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| Problem Focused |
One to five elements
identified by a bullet. |
| Expanded Problem Focused |
At least six elements
identified by a bullet. |
| Detailed |
At least nine elements
identified by a bullet. |
| Comprehensive |
Perform all elements
identified by a bullet; document every element in each shaded box and at least one element
in each unshaded box. |
Genitourinary Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
|
| Eyes |
|
| Ears, Nose, Mouth and Throat |
|
| Neck |
- Examination of neck (eg, masses, overall appearance, symmetry, tracheal
position, crepitus)
- Examination of thyroid (eg, enlargement, tenderness, mass)
|
| Respiratory |
- Assessment of respiratory effort (eg, intercostal retractions, use of
accessory muscles, diaphragmatic movement)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
|
| Cardiovascular |
- Auscultation of heart with notation of abnormal sounds and murmurs
- Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
|
| Chest (Breasts) |
[See genitourinary (female)] |
Gastrointestinal
(Abdomen) |
- Examination of abdomen with notation of presence of masses or tenderness
- Examination for presence or absence of hernia
- Examination of liver and spleen
- Obtain stool sample for occult blood test when indicated
|
| Genitourinary |
MALE:
- Inspection of anus and perineum
Examination (with or without specimen collection for smears and
cultures) of genitalia including:
- Scrotum (eg, lesions, cysts, rashes)
- Epididymides (eg, size, symmetry, masses)
- Testes (eg, size, symmetry, masses)
- Urethral meatus (eg, size, location, lesions, discharge)
- Penis (eg, lesions, presence or absence of foreskin, foreskin
retractability, plaque, masses, scarring, deformities)
Digital rectal examination including:
- Prostate gland (eg, size, symmetry, nodularity, tenderness)
- Seminal vesicles (eg, symmetry, tenderness, masses, enlargement)
- Sphincter tone, presence of hemorrhoids, rectal masses
|
| |
FEMALE:
Includes at least seven of the following eleven
elements identified by bullets:
- Inspection and palpation of breasts (eg, masses or lumps, tenderness,
symmetry, nipple discharge)
- Digital rectal examination including sphincter tone, presence of
hemorrhoids, rectal masses
Pelvic examination (with or without specimen collection for smears and
cultures) including:
- External genitalia (eg, general appearance, hair distribution, lesions)
- Urethral meatus (eg, size, location, lesions, prolapse)
- Urethra (eg, masses, tenderness, scarring)
- Bladder (eg, fullness, masses, tenderness)
- Vagina (eg, general appearance, estrogen effect, discharge, lesions,
pelvic support, cystocele, rectocele)
- Cervix (eg, general appearance, lesions, discharge)
- Uterus (eg, size, contour, position, mobility, tenderness, consistency,
descent or support)
- Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
- Anus and perineum
|
| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
|
| Musculoskeletal |
|
| Extremities |
|
| Skin |
- Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes,
lesions, ulcers)
|
| Neurological/ Psychiatric |
Brief assessment of mental status including
- Orientation (eg, time, place and person) and
- Mood and affect (eg, depression, anxiety, agitation)
|
| |
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
Hematologic/Lymphatic/Immunologic
Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
- Palpation and/or percussion of face with notation of presence or absence
of sinus tenderness
|
| Eyes |
- Inspection of conjunctivae and lids
|
| Ears, Nose, Mouth and Throat |
- Otoscopic examination of external auditory canals and tympanic membranes
- Inspection of nasal mucosa, septum and turbinates
- Inspection of teeth and gums
- Examination of oropharynx (eg, oral mucosa, hard and soft palates,
tongue, tonsils, posterior pharynx)
|
| Neck |
- Examination of neck (eg, masses, overall appearance, symmetry, tracheal
position, crepitus)
- Examination of thyroid (eg, enlargement, tenderness, mass)
|
| Respiratory |
- Assessment of respiratory effort (eg, intercostal retractions, use of
accessory muscles, diaphragmatic movement)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
|
| Cardiovascular |
- Auscultation of heart with notation of abnormal sounds and murmurs
- Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
- Examination of abdomen with notation of presence of masses or tenderness
- Examination of liver and spleen
|
| Genitourinary |
|
| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin, and/or other location
|
| Musculoskeletal |
|
| Extremities |
- Inspection and palpation of digits and nails (eg, clubbing, cyanosis,
inflammation, petechiae, ischemia, infections, nodes)
|
| Skin |
- Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes,
lesions, ulcers, ecchymoses, bruises)
|
| Neurological/ Psychiatric |
Brief assessment of mental status including
- Orientation to time, place and person
- Mood and affect (eg, depression, anxiety, agitation)
|
| |
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
Musculoskeletal
Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
|
| Eyes |
|
| Ears, Nose, Mouth and Throat |
|
| Neck |
|
| Respiratory |
|
| Cardiovascular |
- Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
|
| Genitourinary |
|
| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
|
| Musculoskeletal |
- Examination of gait and station
Examination of joint(s), bone(s) and muscle(s)/ tendon(s) of
four 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; and
6) left lower extremity.
The examination of a given area includes:
- Inspection, percussion and/or palpation with notation of any
misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
- Assessment of range of motion with notation of any pain (eg, straight leg
raising), crepitation or contracture
- Assessment of stability with notation of any dislocation (luxation),
subluxation or laxity
- Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements
NOTE: For the comprehensive level of examination, all four of the
elements identified by a bullet must be performed and documented for each of four anatomic
areas. For the three lower levels of examination, each element is counted separately for
each body area. For example, assessing range of motion in two extremities constitutes two
elements. |
| Extremities |
[See musculoskeletal and skin] |
| Skin |
- Inspection and/or palpation of skin and subcutaneous tissue (eg, scars,
rashes, lesions, cafe-au-lait spots, ulcers) in four of the following six
areas:
1) head and neck;
2) trunk;
3) right upper extremity;
4) left upper extremity;
5) right lower extremity; and
6) left lower extremity.
NOTE: For the comprehensive level, the examination of all four anatomic
areas must be performed and documented. For the three lower levels of examination, each
body area is counted separately. For example, inspection and/or palpation of the skin and
subcutaneous tissue of two extremitites constitutes two elements. |
Neurological/
Psychiatric |
- Test coordination (eg, finger/nose, heel/ knee/shin, rapid alternating
movements in the upper and lower extremities, evaluation of fine motor coordination in
young children)
- Examination of deep tendon reflexes and/or nerve stretch test with
notation of pathological reflexes (eg, Babinski)
- Examination of sensation (eg, by touch, pin, vibration, proprioception)
Brief assessment of mental status including
- Orientation to time, place and person
- Mood and affect (eg, depression, anxiety, agitation)
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
Neurological Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
|
| Eyes |
- Ophthalmoscopic examination of optic discs (eg, size, C/D ratio,
appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
|
| Ears, Nose, Mouth and
Throat |
|
| Neck |
|
| Respiratory |
|
| Cardiovascular |
- Examination of carotid arteries (eg, pulse amplitude, bruits)
- Auscultation of heart with notation of abnormal sounds and murmurs
- Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
|
| Genitourinary |
|
| Lymphatic |
|
| Musculoskeletal |
- Examination of gait and station
Assessment of motor function including:
- Muscle strength in upper and lower extremities
- Muscle tone in upper and lower extremities (eg, flaccid, cog wheel,
spastic) with notation of any atrophy or abnormal movements (eg, fasciculation, tardive
dyskinesia)
|
| Extremities |
[See musculoskeletal] |
| Skin |
|
| Neurological |
Evaluation of higher
integrative functions including:
- Orientation to time, place and person
- Recent and remote memory
- Attention span and concentration
- Language (eg, naming objects, repeating phrases, spontaneous speech)
- Fund of knowledge (eg, awareness of current events, past history,
vocabulary)
Test the following cranial nerves:
- 2nd cranial nerve (eg, visual acuity, visual fields, fundi)
- 3rd, 4th and 6th cranial nerves (eg, pupils, eye movements)
- 5th cranial nerve (eg, facial sensation, corneal reflexes)
- 7th cranial nerve (eg, facial symmetry, strength)
- 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or
finger rub)
- 9th cranial nerve (eg, spontaneous or reflex palate movement)
- 11th cranial nerve (eg, shoulder shrug strength)
- 12th cranial nerve (eg, tongue protrusion)
- Examination of sensation (eg, by touch, pin, vibration, proprioception)
- Examination of deep tendon reflexes in upper and lower extremities with
notation of pathological reflexes (eg, Babinski)
- Test coordination (eg, finger/nose, heel/knee/shin, rapid
|
| Psychiatric |
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
Psychiatric Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
|
| Eyes |
|
| Ears, Nose, Mouth and Throat |
|
| Neck |
|
| Respiratory |
|
| Cardiovascular |
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
|
| Genitourinary |
|
| Lymphatic |
|
| Musculoskeletal |
- Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic)
with notation of any atrophy and abnormal movements
- Examination of gait and station
|
| Extremities |
|
| Skin |
|
| Neurological |
|
| Psychiatric |
- Description of speech including: rate; volume; articulation; coherence;
and spontaneity with notation of abnormalities (eg, perseveration, paucity of language)
- Description of thought processes including: rate of thoughts; content of
thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation
- Description of associations (eg, loose, tangential, circumstantial,
intact)
- Description of abnormal or psychotic thoughts including: hallucinations;
delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions
- Description of the patient's judgment (eg, concerning everyday activities
and social situations) and insight (eg, concerning psychiatric condition)
Complete mental status examination including
- Orientation to time, place and person
- Recent and remote memory
- Attention span and concentration
- Language (eg, naming objects, repeating phrases)
- Fund of knowledge (eg, awareness of current events, past history,
vocabulary)
- Mood and affect (eg, depression, anxiety, agitation, hypomania, lability)
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| Problem Focused |
One to five elements
identified by a bullet. |
| Expanded Problem Focused |
At least six elements
identified by a bullet. |
| Detailed |
At least nine elements
identified by a bullet. |
| Comprehensive |
Perform all elements
identified by a bullet; document every element in each shaded box and at least one element
in each unshaded box. |
Respiratory Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
|
| Eyes |
|
| Ears, Nose, Mouth and Throat |
- Inspection of nasal mucosa, septum and turbinates
- Inspection of teeth and gums
- Examination of oropharynx (eg, oral mucosa, hard and soft palates,
tongue, tonsils and posterior pharynx)
|
| Neck |
- Examination of neck (eg, masses, overall appearance, symmetry, tracheal
position, crepitus)
- Examination of thyroid (eg, enlargement, tenderness, mass)
- Examination of jugular veins (eg, distension; a, v or cannon a waves)
|
| Respiratory |
- Inspection of chest with notation of symmetry and expansion
- Assessment of respiratory effort (eg, intercostal retractions, use of
accessory muscles, diaphragmatic movement)
- Percussion of chest (eg, dullness, flatness, hyperresonance)
- Palpation of chest (eg, tactile fremitus)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
|
| Cardiovascular |
- Auscultation of heart including sounds, abnormal sounds and murmurs
- Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
- Examination of abdomen with notation of presence of masses or tenderness
- Examination of liver and spleen
|
| Genitourinary |
|
| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
|
| Musculoskeletal |
- Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic)
with notation of any atrophy and abnormal movements
- Examination of gait and station
|
| Extremities |
- Inspection and palpation of digits and nails (eg, clubbing, cyanosis,
inflammation, petechiae, ischemia, infections, nodes)
|
| Skin |
- Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes,
lesions, ulcers)
|
| Neurological/ Psychiatric |
Brief assessment of mental status including
- Orientation to time, place and person
- Mood and affect (eg, depression, anxiety, agitation)
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
Skin Examination
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 by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus,
deformities, attention to grooming)
|
| Head and Face |
|
| Eyes |
- Inspection of conjunctivae and lids
|
| Ears, Nose, Mouth and Throat |
- Inspection of lips, teeth and gums
- Examination of oropharynx (eg, oral mucosa, hard and soft palates,
tongue, tonsils, posterior pharynx)
|
| Neck |
- Examination of thyroid (eg, enlargement, tenderness, mass)
|
| Respiratory |
|
| Cardiovascular |
- Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
|
| Chest (Breasts) |
|
| Gastrointestinal (Abdomen) |
- Examination of liver and spleen
- Examination of anus for condyloma and other lesions
|
| Genitourinary |
|
| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
|
| Musculoskeletal |
|
| Extremities |
- Inspection and palpation of digits and nails (eg, clubbing, cyanosis,
inflammation, petechiae, ischemia, infections, nodes)
|
| Skin |
- Palpation of scalp and inspection of hair of scalp, eyebrows, face,
chest, pubic area (when indicated) and extremities
Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes,
lesions, ulcers, susceptibility to and presence of photo damage) in four of the
following five areas:
1) head and neck;
2) chest, breasts, and back;
3) abdomen;
4) genitalia; and
5) extremities
NOTE: For the comprehensive level, the examination of all four anatomic
areas must be performed and documented. For the three lower levels of examination, each
body area is counted separately. For example, inspection and/or palpation of the skin and
subcutaneous tissue of the head and neck and extremities constitutes two areas.
- Inspection of eccrine and apocrine glands of skin and subcutaneous tissue
with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis
|
| Neurological/Psychiatric |
Brief assessment of mental status including
- Orientation to time, place and person
- Mood and affect (eg, depression, anxiety, agitation)
|
Content and Documentation Requirements
| Level of Exam |
Perform and Document: |
| 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 shaded box and at least one element
in each unshaded box. |
C. DOCUMENTATION
OF THE COMPLEXITY OF MEDICAL DECISION MAKING
The levels of E/M services recognize four types of medical decision making
(straight-forward, low complexity, moderate complexity and high complexity). Medical
decision making refers to the complexity of establishing a diagnosis and/or selecting a
management option as measured by:
- the number of possible diagnoses and/or the number of management options that must be
considered;
- the amount and/or complexity of medical records, diagnostic tests, and/or other
information that must be obtained, reviewed and analyzed; and
- the risk of significant complications, morbidity and/or mortality, as well as
comorbidities, associated with the patient's presenting problem(s), the diagnostic
procedure(s) and/or the possible management options.
The chart below shows the progression of the elements required for each level of
medical decision making. To qualify for a given type of decision making, two of
the three elements in the table must be either met or exceeded.
| Number of diagnoses or management options |
Amount and/or complexity of data to be reviewed |
Risk of complications and/or morbidity or mortality |
Type of decision making |
| Minimal |
Minimal or None |
Minimal |
Straightforward |
| Limited |
Limited |
Low |
Low Complexity |
| Multiple |
Moderate |
Moderate |
Moderate Complexity |
| Extensive |
Extensive |
High |
High Complexity |
Each of the elements of medical decision making is described below.
NUMBER OF DIAGNOSES OR
MANAGEMENT OPTIONS
The number of possible diagnoses and/or the number of management options that must be
considered is based on the number and types of problems addressed during the encounter,
the complexity of establishing a diagnosis and the management decisions that are made by
the physician.
Generally, decision making with respect to a diagnosed problem is easier than that for
an identified but undiagnosed problem. The number and type of diagnostic tests employed
may be an indicator of the number of possible diagnoses. Problems which are improving or
resolving are less complex than those which are worsening or failing to change as
expected. The need to seek advice from others is another indicator of complexity of
diagnostic or management problems.
DG: For each encounter, an assessment, clinical impression, or
diagnosis should be documented. It may be explicitly stated or implied in documented
decisions regarding management plans and/or further evaluation.
- For a presenting problem with an established diagnosis the record should reflect
whether the problem is: a) improved, well controlled, resolving or resolved; or, b)
inadequately controlled, worsening, or failing to change as expected.
- For a presenting problem without an established diagnosis, the assessment or
clinical impression may be stated in the form of differential diagnoses or as a
"possible", "probable", or "rule out" (R/O) diagnosis.
DG: The initiation of, or changes in, treatment should be
documented. Treatment includes a wide range of management options including patient
instructions, nursing instructions, therapies, and medications.
DG: If referrals are made, consultations requested or advice
sought, the record should indicate to whom or where the referral or consultation is made
or from whom the advice is requested.
AMOUNT AND/OR
COMPLEXITY OF DATA TO BE REVIEWED
The amount and complexity of data to be reviewed is based on the types of diagnostic
testing ordered or reviewed. A decision to obtain and review old medical records and/or
obtain history from sources other than the patient increases the amount and complexity of
data to be reviewed.
Discussion of contradictory or unexpected test results with the physician who performed
or interpreted the test is an indication of the complexity of data being reviewed. On
occasion the physician who ordered a test may personally review the image, tracing or
specimen to supplement information from the physician who prepared the test report or
interpretation; this is another indication of the complexity of data being reviewed.