Documentation of Examination (1995 and 1997)

The levels of E/M services are based on four types of examination that are defined as follows:

·         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 other symptomatic or related organ system(s).

·         Detailed-- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

·         Comprehensive -- a general multi-system examination or complete examination of a single organ system.

 

For purposes of 1995 examination, 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

 

For purposes of 1995 examination, the following organ systems are recognized:

·         Constitutional (e.g., vital signs, general appearance)

·         Eyes

·         Ears, nose, mouth, and throat

·         Cardiovascular

·         Respiratory

·         Gastrointestinal

·         Genitourinary

·         Musculoskeletal

·         Skin

·         Neurologic

·         Psychiatric

·         Hematologic/lymphatic/immunologic

 

The extent of 1997 examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

***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.

*** Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described.

***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).

***The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.

 

Parenthetical examples “(e.g.,…)” 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.

***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.

***Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

***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).