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1997 Documentation Guidelines for Evaluation
and Management Services
TABLE OF CONTENTS
TOC \f
Introduction 2
What Is Documentation and Why Is it Important? 2
What Do Payers Want and Why? 2
General Principles of Medical Record Documentation 3
Documentation of E/M Services . 4
Documentation of History 5
Chief Complaint (CC) 6
History of Present Illness (HPI) 7
Review of Systems (ROS) 8
Past, Family and/or Social History (PFSH) 9
Documentation of Examination 10
General Multi-System Examinations 11
Single Organ System Examinations 12
Content and Documentation Requirements 13
General Multi-System Examination 13
Cardiovascular Examination 18
Ear, Nose and Throat Examination 20
Eye Examination 23
Genitourinary Examination 25
Hematologic/Lymphatic/Immunologic Examination 29
Musculoskeletal Examination 31
Neurological Examination 34
Psychiatric Examination 37
Respiratory Examination 39
Skin Examination 41
Documentation of the Complexity of Medical Decision Making 43
Number of Diagnoses or Management Options 44
Amount and/or Complexity of Data to Be Reviewed 45
Risk of Significant Complications, Morbidity, and/or Mortality 46
Table of Risk 47
Documentation of an Encounter Dominated by Counseling or Coordination of Care 48
1997 DOCUMENTATION GUIDELINES
FOR EVALUATION AND MANAGEMENT SERVICES
I. INTRODUCTIONtc \l1 "INTRODUCTION
WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?tc \l2 "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?tc \l2 "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 DOCUMENTATIONtc \l1 "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 SERVICEStc \l1 "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 HISTORYtc \l1 "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:
describing any new ROS and/or PFSH information or noting there has been no change in the information; and
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) tc \l2 "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)tc \l2 "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)tc \l2 "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)tc \l2 "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 EXAMINATIONtc \l1 "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 ther 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 patients 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 EXAMINATIONStc \l2 "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 EXAMINATIONStc \l2 "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 box with a shaded or unshaded border.
Expanded Problem Focused Examination--should include performance and documentation of at least six elements identified by a bullet (), whether in a box with a shaded or unshaded border.
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 box with a shaded or unshaded border.
Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (), whether in a box with a shaded or unshaded border.
Comprehensive Examination--should include performance of all elements identified by a bullet (), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.
CONTENT AND DOCUMENTATION REQUIREMENTStc \l2 "CONTENT AND DOCUMENTATION REQUIREMENTS
General Multi-System Examinationtc \l3 "General Multi-System Examination
System/Body Area
Elements of Examination
Constitutional
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n , 5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
E y e s
I n s p e c t i o n o f c o n j u n c t i v a e a n d l i d s
E x a m i n a t i o n o f p u p i l s a n d i r i s e s ( e g , r e a c t i o n t o l i g h t a n d a c c o m m o d a t i o n , s i z e a n d s y m m e t r y )
O p h t h a l m o s c o p i c e x a m i n a t i o n o f o p t i c d i s c s ( e g , s i z e , C / D r a t i o , a p p e a r a n c e ) a n d p o s t e r i o r s e g m e n t s ( e g , v e s s e l c h a n g e s , e x u d a t e s , h e m o r r h a g e s )
E a r s , N o s e , M o u t h a n d T h r o a t
E x t e r n a l i n s p e c t i o n o f e a r s a n d n o s e ( e g , o v e r a l l a p p e a r a n c e , s c a r s , l e s i o n s , m a s s e s )
O t o s c o p i c e x a m i n a t i o n o f e x t e r n a l a u d i t o r y c a n a l s a n d t y m p a n i c m e m b r a n e s
A s s e s s m e n t o f h e a r i n g ( e g , w h i s p e r e d v o i c e , f i n g e r r u b , t u n i n g f o r k )
I n s p e c t i o n o f n a s a l m u c o s a , s e p t u m a n d t u r b i n a t e s
I n s p e c t i o n o f l i p s , t e e t h a n d g u m s
E x a m i n a t i o n o f o r o p h a r y n x : o r a l m u c o s a , s a l i v a r y g l a n d s , h a r d a n d s o f t p a l a t e s , t o n g u e , t o n s i l s a n d p o s t e r i o r p h a r y n x
N e c k
E x a m i n a t i o n o f n e c k ( e g , m a s s e s , o v e r a l l a p p e a r a n c e , s y m m e t r y , t r a c h e a l p o s i t i o n , c r e p i t u s )
E x a m i n a t i o n o f t h y r o i d ( e g , e n l a r g e m e n t , t e n d e r n e s s , m a s s )
R e s p i r a t o r y
A s s e s s m e n t o f r e s p i r a t o r y e f f o r t ( e g , i n t e r c o s t a l r e t r a c t i o n s , u s e o f a c c e s s o r y m u s c l e s , d i a p h r a g m a t i c m o v e m e n t )
P e r c u s s i o n o f c h e s t ( e g , d u l l n e s s , f l a t n e s s , h y p e r r e s o n a n c e )
P a l p a t i o n o f c h e s t ( e g , t a c t i l e f r e m i t u s )
A u s c u l t a t i o n o f l u n g s ( e g , b r e a t h s o u n d s , a d v e n t i t i o u s s o u n d s , r u b s )
C a r d i o v a s c u l a r
P a l p a t i o n o f h e a r t ( e g , l o c a t i o n , s i z e , t h r i l l s )
A u s c u l t a t i o n o f h e a r t w i t h n o t a t i o n o f a b n o r m a l s o u n d s a n d m u r m u r s
E x a m i n a t i o n o f :
c a r o t i d a r t e r i e s ( e g , p u l s e a m p l i t u d e , b r u i t s )
a b d o m i n a l a o r t a ( e g , s i z e , b r u i t s )
f e m o r a l a r t e r i e s ( e g , p u l s e a m p l i t u d e , b r u i t s )
p e d a l p u l s e s ( e g , p u l s e a m p l i t u d e )
e x t r e m i t i e s f o r e d e m a a n d / o r v a r i c o s i t i e s
C h e s t ( B r e a s t s )
I n s p e c t i o n o f b r e a s t s ( e g , s y m m e t r y , n i p p l e d i s c h a r g e )
P a l p a t i o n o f b r e a s t s a n d a x i l l a e ( e g , m a s s e s o r l u m p s , t e n d e r n e s s )
G a s t r o i n t e s t i n a l
( A b d o m e n )
E x a m i n a t i o n o f a b d o m e n w i t h n o t a t i o n o f p r e s e n c e o f m a s s e s o r t e n d e r n e s s
E x a m i n a t i o n o f l i v e r a n d s p l e e n
E x a m i n a t i o n f o r p r e s e n c e o r a b s e n c e o f h e r n i a
E x a m i n a t i o n ( w h e n i n d i c a t e d ) o f a n u s , p e r i n e u m a n d r e c t u m , i n c l u d i n g s p h i n c t e r t o n e , p r e s e n c e o f h e m o r r h o i d s , r e c t a l m a s s e s
O b t a i n s t o o l s a m p l e f o r o c c u l t b l o o d t e s t w h e n i n d i c a t e d
G e n i t o u r i n a r y
M A L E :
E x a m i n a t i o n o f t h e s c r o t a l c o n t e n t s ( e g , h y d r o c e l e , s p e r m a t o c e l e , t e n d e r n e s s o f c o r d , t e s t i c u l a r m a s s )
E x a m i n a t i o n o f t h e p e n i s
D i g i t a l r e c t a l e x a m i n a t i o n o f p r o s t a t e g l a n d ( e g , s i z e , s y m m e t r y , n o d u l a r i t y , t e n d e r n e s s )
F E M A L E :
P e l v i c e x a m i n a tion (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)
U t e r u s ( e g , s i z e , c o n t o u r , p o s i t i o n , m o b i l i t y , t e n d e r n e s s , c o n s i s t e n c y , d e s c e n t o r s u p p o r t )
A d n e x a / p a r a m e t r i a ( e g , m a s s e s , t e n d e r n e s s , o r g a n o m e g a l y , n o d u l a r i t y )
L y m p h a t i c
P a l p a t i o n o f l y m p h n o d e s i n t w o o r m o r e a r e a s :
N e c k
A x i l l a e
G r o i n
O t h e r
M u s c u l o s k e l e t a l
E x a m i n a t i o n o f g a i t a n d s t a t i o n
I n s p e c t i o n a n d / o r p a l p a t i o n o f d i g i t s a n d n a i l s ( e g , c l u b b i n g , c y a n o s i s , i n f l a m m a t o r y c o n d i t i o n s , p e t e c h i a e , i s c h e m i a , i n f e c t i o n s , n o d e s )
E x a m i n a t i o n o f j o i n t s , b o n e s a n d m u s c l e s o f o n e o r 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 dislo c a t i o n ( l u x a t i o n ) , s u b l u x a t i o n o r l a x i t y
A s s e s s m e n t o f m u s c l e s t r e n g t h a n d t o n e ( e g , f l a c c i d , c o g w h e e l , s p a s t i c ) w i t h n o t a t i o n o f a n y a t r o p h y o r a b n o r m a l m o v e m e n t s
S k i n
I n s p e c t i o n o f s k i n a n d s u b c u t a n e o u s t i s s u e ( e g , r a s h e s , l e s i o n s , u l c e r s )
P a l p a t i o n o f s k i n a n d s u b c u t a n e o u s t i s s u e ( e g , i n d u r a t i o n , s u b c u t a n e o u s n o d u l e s , t i g h t e n i n g )
N e u r o l o g i c
T e s t c r a n i a l n e r v e s w i t h n o t a t i o n o f a n y d e f i c i t s
E x a m i n a t i o n o f d e e p t e n d o n r e f l e x e s w i t h n o t a t i o n o f p a t h o l o g i c a l r e f l e x e s ( e g , B a b i n s k i )
E x a m i n a t i o n o f s e n s a t i o n ( e g , b y t o u c h , p i n , v i b r a t i o n , p r o p r i o c e p t i o n )
P s y c h i a t r i c
D e s c r i p t i o n o f p a t i e n t s j u d g m e n t a n d i n s i g h t
B r i e f a s s e s s m e n t o f m e n t a l s t a t u s i n c l u d i n g :
o r i e n t a t i o n t o t i m e , p l a c e a n d p e r s o n
r e c e n t a n d r e m o t e m e m o r y
m o o d 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 Examinationtc \l3 "Cardiovascular Examination
System/Body Area
Elements of Examination
Constitutional
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
H e a d a n d F a c e
E y e s
I n s p e c t i o n o f c o n j u n c t i v a e a n d l i d s ( e g , x a n t h e l a s m a )
E a r s , N o s e , M o u t h a n d T h r o a t
I n s p e c t i o n o f t e e t h , g u m s a n d p a l a t e
I n s p e c t i o n o f o r a l m u c o s a w i t h n o t a t i o n o f p r e s e n c e o f p a l l o r o r c y a n o s i s
N e c k
E x a m i n a t i o n o f j u g u l a r v e i n s ( e g , d i s t e n s i o n ; a , v o r c a n n o n a w a v e s )
E x a m i n a t i o n o f t h y r o i d ( e g , e n l a r g e m e n t , t e n d e r n e s s , m a s s )
R e s p i r a t o r y
A s s e s s m e n t o f r e s p i r a t o r y e f f o r t ( e g , i n t e r c o s t a l r e t r a c t i o n s , u s e o f a c c e s s o r y m u s c l e s , d i a p h r a g m a t i c m o v e m e n t )
A u s c u l t a t i o n o f l u n g s ( e g , b r e a t h s o u n d s , a d v e n t i t i o u s s o u n d s , r u b s )
C a r d i o v a s c u l a r
P a l p a t i o n o f h e a r t ( e g , l o c a t i o n , s i z e a n d f o r c e f u l n e s s o f t h e p o i n t o f m a x i m a l i m p a c t ; t h r i l l s ; l i f t s ; p a l p a b l e S 3 o r S 4 )
A u s c u l t a t i o n o f h e a r t i n c l u d i n g s o u n d s , a b n o r m a l s o u n d s a n d m u r m u r s
M e a s u r e m e n t o f b l o o d p r e s s u r e i n t w o o r m o r e e x t r e m i t i e s w h e n i n d i c a t e d ( e g , a o r t i c d i s s e c t i o n , c o a r c t a t i o n )
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)
E x a m i n a t i o n o f a b d o m e n w i t h n o t a t i o n o f p r e s e n c e o f m a s s e s o r t e n d e r n e s s
E x a m i n a t i o n o f l i v e r a n d s p l e e n
O b t a i n s t o o l s a m p l e f o r o c c u l t b l o o d f r o m p a t i e n t s w h o a r e b e i n g c o n s i d e r e d f o r t h r o m b o l y t i c o r a n t i c o a g u l a n t t h e r a p y
G e n i t o u r i n a r y
( A b d o m e n )
L y m p h a t i c
M u s c u l o s k e l e t a l
E x a m i n a t i o n o f t h e b a c k w i t h n o t a t i o n o f k y p h o s i s o r s c o l i o s i s
E x a m i n a t i o n o f g a i t w i t h n o t a t i o n o f a b i l i t y t o u n d e r g o e x e r c i s e t e s t i n g a n d / o r p a r t i c i p a t i o n i n e x e r c i s e p r o g r a m s
A s s e s s m e n t o f m u s c l e s t r e n g t h a n d t o n e ( e g , f l a c c i d , c o g w h e e l , s p a s t i c ) w i t h n o t a t i o n o f a n y a t r o p h y a n d a b n o r m a l m o v e m e n t s
E x t r e m i t i e s
I n s p e c t i o n a n d p a l p a t i o n o f d i g i t s a n d n a i l s ( e g , c l u b b i n g , c y a n o s i s , i n f l a m m a t i o n , p e t e c h i a e , i s c h e m i a , i n f e c t i o n s , O s l e r s n o d e s )
S k i n
I n s p ection 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 box with a shaded border and at least one element in each box with an unshaded border.
Ear, Nose and Throat Examinationtc \l3 "Ear, Nose and Throat Examination
System/Body Area
Elements of Examination
Constitutional
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
A s s e s s m e n t o f a b i l i t y t o c o m m u n i c a t e ( e g , u s e o f s i g n l a n g u a g e o r o t h e r c o m m u n i c a t i o n a i d s ) a n d q u a l i t y o f v o i c e
H e a d a n d F a c e
I n s p e c t i o n o f h e a d a n d f a c e ( e g , o v e r a l l a p p e a r a n c e , s c a r s , l e s i o n s a n d m a s s e s )
P a l p a t i o n a n d / o r p e r c u s s i o n o f f a c e w i t h n o t a t i o n o f p r e s e n c e o r a b s e n c e o f s i n u s t e n d e r n e s s
E x a m i n a t i o n o f s a l i v a r y g l a n d s
A s s e s s m e n t o f f a c i a l s t r e n g t h
E y e s
T e s t o c u l a r m o t i l i t y i n c l u d i n g p r i m a r y g a z e a l i g n m e n t
E a r s , N o s e , M o u t h
a n d T h r o a t
O t o s c o p i c e x a m i n a t i o n o f e x t e r n a l a u d i t o r y c a n a l s a n d t y m p a n i c m e m b r a n e s i n c l u d i n g p n e u m o - o t o s c o p y w i t h n o t a t i o n o f m o b i l i t y o f m e m b r a n e s
A s s e s s m e n t o f h e a r i n g w i t h t u n i n g f o r k s a n d c l i n i c a l s p e e c h r e c e p t i o n t h r e s h o l d s ( e g , w h i s p e r e d v o i c e , f i n g e r r u b )
E x t e r n a l i n s p e c t i o n o f e a r s a n d n o s e ( e g , o v e r a l l a p p e a r a n c e , s c a r s , l e s i o n s a n d m a s s e s )
I n s p e c t i o n o f n a s a l m u c o s a , s e p t u m a n d t u r b i n a t e s
I n s p e c t i o n o f l i p s , t e e t h a n d g u m s
E x a m i n a t i o n o f o r o p h a r y n x : o r a l m u c o s a , h a r d a n d s o f t p a l a t e s , t o n g u e , t o n s i l s a n d p o s t e r i o r p h a r y n x ( e g , a s y m m e t r y , l e s i o n s , h y d r a t i o n o f m u c o s a l s u r f a c e s )
I n s p e c t i o n o f p h a r y n g e a l w a l l s a n d p y r i f o r m s i n u s e s ( e g , p o o l i n g o f s a l i v a , a s y m m e t r y , l e s i o n s )
E x a m i n a t i o n b y m i r r o r o f l a r y n x i n c l u d i n g t h e c o n d i t i o n o f t h e e p i g l o t t i s , f a l s e v o c a l c o r d s , t r u e v o c a l c o r d s a n d m o b i l i t y o f l a r y n x ( U s e o f m i r r o r n o t r e q u i r e d i n c h i l d r e n )
E x a m i n a t i o n b y m i r r o r o f n a s o p h a r y n x i n c l u d i n g a p p e a r a n c e o f t h e m u c o s a , a d e n o i d s , p o s t e r i o r c h o a n a e a n d e u s t a c h i a n t u b e s ( U s e o f m i r r o r n o t r e q u i r e d i n c h i l d r e n )
N e c k
E x a m i n a t i o n o f n e c k ( e g , m a s s e s , o v e r a l l a p p e a r a n c e , s y m m e t r y , t r a c h e a l p o s i t i o n , c r e p i t u s )
E x a m i n a t i o n o f t h y r o i d ( e g , e n l a r g e m e n t , t e n d e r n e s s , m a s s )
R e s p i r a t o r y
I n s p e c t i o n o f c h e s t i n c l u d i n g s y m m e t r y , e x p a n s i o n a n d / o r a s s e s s m e n t o f r e s p i r a t o r y e f f o r t ( e g , i n t e r c o s t a l r e t r a c t i o n s , u s e o f a c c e s s o r y m u s c l e s , d i a p h r a g m a t i c m o v e m e n t )
A u s c u l t a t i o n o f l u n g s ( e g , b r e a t h s o u n d s , a d v e n t i t i o u s s o u n d s , r u b s )
C a r d i o v a s c u l a r
A u s c u l t a t i o n o f h e a r t w i t h n o t a t i o n o f a b n o r m a l s o u n d s a n d m u r m u r s
E x a m i n a t i o n o f p e r i p h e r a l v a s c u l a r s y s t e m b y o b s e r v a t i o n ( e g , s w e l l i n g , v a r i c o s i t i e s ) a n d p a l p a t i o n ( e g , p u l s e s , t e m p e r a t u r e , e d e m a , t e n d e r n e s s )
C h e s t ( B r e a s t s )
G a s t r o i n t e s t i n a l
( A b d o m e n )
G e n i t o u r i n a r y
L y m p h a t i c
P a l p a t i o n o f l y m p h n o d e s i n n e c k , a x i l l a e , g r o i n a n d / o r o t h e r l o c a t i o n
M u s c u l o s k e l e t a l
E x t r e m i t i e s
S k i n
N e u r o l o g i c a l /
P s y c h i a t r i c
T e s t c r a n i a l n e r ves 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 box with a shaded border and at least one element in each box with an unshaded border.
Eye Examinationtc \l3 "Eye Examination
System/Body Area
Elements of Examination
Constitutional
Head and Face
Eyes
T e s t v i s u a l a c u i t y ( D o e s n o t i n c l u d e d e t e r m i n a t i o n o f r e f r a c t i v e e r r o r )
G r o s s v i s u a l f i e l d t e s t i n g b y c o n f r o n t a t i o n
T e s t o c u l a r m o t i l i t y i n c l u d i n g p r i m a r y g a z e a l i g n m e n t
I n s p e c t i o n o f b u l b a r a n d p a l p e b r a l c o n j u n c t i v a e
E x a m i n a t i o n o f o c u l a r a d n e x a e i n c l u d i n g l i d s ( e g , p t o s i s o r l a g o p h t h a l m o s ) , l a c r i m a l g l a n d s , l a c r i m a l d r a i n a g e , o r b i t s a n d p r e a u r i c u l a r l y m p h n o d e s
E x a m i n a t i o n o f p u p i l s a n d i r i s e s i n c l u d i n g s h a p e , d i r e c t a n d c o n s e n s u a l r e a c t i o n ( a f f e r e n t p u p i l ) , s i z e ( e g , a n i s o c o r i a ) a n d m o r p h o l o g y
S l i t l a m p e x a m i n a t i o n o f t h e c o r n e a s i n c l u d i n g e p i t h e l i u m , s t r o m a , e n d o t h e l i u m , a n d t e a r f i l m
S l i t l a m p e x a m i n a t i o n o f t h e a n t e r i o r c h a m b e r s i n c l u d i n g d e p t h , c e l l s , a n d f l a r e
S l i t l a m p e x a m i n a t i o n o f t h e l e n s e s i n c l u d i n g c l a r i t y , a n t e r i o r a n d p o s t e r i o r c a p s u l e , c o r t e x , a n d n u c l e u s
M e a s u r e m e n t o f i n t r a o c u l a r p r e s s u r e s ( e x c e p t i n c h i l d r e n a n d p a t i e n t s w i t h t r a u m a o r i n f e c t i o u s d i s e a s e )
O p h t h a l m o s c o p i c e x a m i n a t i o n t h r o u g h d i l a t e d p u p i l s ( u n l e s s c o n t r a i n d i c a t e d ) o f
O p t i c d i s c s i n c l u ding size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer
Posterior segments including retina and vessels (eg, exudates and hemorrhages)
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 box with a shaded border and at least one element in each box with an unshaded border.
G e n i t o u r i n a r y E x a m i n a t i o n t c \ l 3 " G e n i t o u r i n a r y E x a m i n a t i o n
S y s t e m / B o d y A r e a
E l e m e n t s o f E x a m i n a t i o n
C o n s t i t u t i o n a l
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
H e a d a n d F a c e
E y e s
E a r s , N o s e , M o u t h a n d T h r o a t
N e c k
E x a m i n a t i o n o f n e c k ( e g , m a s s e s , o v e r a l l a p p e a r a n c e , s y m m e t r y , t r a c h e a l p o s i t i o n , c r e p i t u s )
E x a m i n a t i o n o f t h y r o i d ( e g , e n l a r g e m e n t , t e n d e r n e s s , m a s s )
R e s p i r a t o r y
A s s e s s m e n t o f r e s p i r a t o r y e f f o r t ( e g , i n t e r c o s t a l r e t r a c t i o n s , u s e o f a c c e s s o r y m u s c l e s , d i a p h r a g m a t i c m o v e m e n t )
A u s c u l t a t i o n o f l u n g s ( e g , b r e a t h s o u n d s , a d v e n t i t i o u s s o u n d s , r u b s )
C a r d i o v a s c u l a r
A u s c u l t a t i o n o f h e a r t w i t h n o t a t i o n o f a b n o r m a l s o u n d s a n d m u r m u r s
E x a m i n a t i o n o f p e r i p h e r a l v a s c u l a r s y s t e m b y o b s e r v a t i o n ( e g , s w e l l i n g , v a r i c o s i t i e s ) a n d p a l p a t i o n ( e g , p u l s e s , t e m p e r a t u r e , e d e m a , t e n d e r n e s s )
C h e s t ( B r e a s t s )
[ S e e g e n i t o u r i n a r y ( f e m a l e ) ]
G a s t r o i n t e s t i n a l
( A b d o m e n )
E x a m i n a t i o n o f a b d o m e n w i t h n o t a t i o n o f p r e s e n c e o f m a s s e s o r t e n d e r n e s s
E x a m i n a t i o n f o r p r e s e n c e o r a b s e n c e o f h e r n i a
E x a m i n a t i o n o f l i v e r a n d s p l e e n
O b t a i n s t o o l s a m p l e f o r o c c u l t b l o o d t e s t w h e n i n d i c a t e d
G e n i t o u r i n a r y
M A L E :
I n s p e c t i o n o f a n u s a n d p e r i n e u m
E x a m i n a t i o n ( w i t h o r w i t h o u t s p e c i m e n c o l l e c t i o n f o r s m e a r s a n d c u l t u r e s ) o f g e n i t a l i a i n c l u d i n g :
S c r o t u m ( e g , l e s i o n s , c y s t s , r a s h e s )
E p i d i d y m i d e s ( e g , s i z e , s y m m e t r y , m a s s e s )
T e s t e s ( e g , s i z e , s y m m e t r y , m a s s e s )
U r e t h r a l m e a t u s ( e g , s i z e , l o c a t i o n , l e s i o n s , d i s c h a r g e )
P e n i s ( e g , l e s i o n s , p r e s e n c e o r a b s e n c e o f f o r e s k i n , f o r e s k i n r e t r a c t a b i l i t y , p l a q u e , m a s s e s , s c a r r i n g , d e f o r m i t i e s )
D i g i t a l r e c t a l e x a m i n a t i o n i n c l u d i n g :
P r o s t a t e g l a n d ( e g , s i z e , s y m m e t r y , n o d u l a r i t y , t e n d e r n e s s )
S e m i n a l v e s i c l e s ( e g , s y m m e t r y , t e n d e r n e s s , m a s s e s , e n l a r g e m e n t )
S p h i n c t e r t o n e , p r e s e n c e o f h e m o r r h o i d s , r e c t a l m a s s e s
G e n i t o u r i n a r y
( C o n t d )
F E M A L E :
I n c l u d e s a t l e a s t s e v e n o f t h e f o l l o w i n g e l e v e n e l e m e n t s i d e n t i f i e d b y b u l l e t s :
I n s p e c t i o n a n d p a l p a t i o n o f b r e a s t s ( e g , m a s s e s o r l u m p s , t e n d e r n e s s , s y m m e t r y , n i p p l e d i s c h a r g e )
D i g i t a l r e c t a l e x a m i n a t i o n i n c l u d i n g s p h i n c t e r t o n e , p r e s e n c e o f h e m o r r h o i d s , r e c t a l m a s s e s
P e l v i c e x a m i n a t i o n ( w i t h o r w i t h o u t s p e c i m e n c o l l e c t i o n f o r s m e a r s a n d c u l t u r e s ) i n c l u d i n g :
E x t e r n a l g e n i t a l i a ( e g , g e n e r a l a p p e a r a n c e , h a i r d i s t r i b u t i o n , l e s i o n s )
U r e t h r a l m e a t u s ( e g , s i z e , l o c a t i o n , l e s i o n s , p r o l a p s e )
U r e t h r a ( e g , m a s s e s , t e n d e r n e s s , s c a r r i n g )
B l a d d e r ( e g , f u l l n e s s , m a s s e s , t e n d e r n e s s )
V a g i n a ( e g , g e neral 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
I n s p e c t i o n a n d / o r p a l p a t i o n o f s k i n a n d s u b c u t a n e o u s t i s s u e ( e g , r a s h e s , l e s i o n s , u l c e r s )
N e u r o l o g i c a l /
P s y c h i a t r i c
B r i e f a s s e s s m e n t o f m e n t a l s t a t u s i n c l u d i n g
O r i e n t a t i o n ( e g , t i m e , p l a c e a n d p e r s o n ) a n d
M o o d a n d a f f e c t ( e g , d e p r e s s i o n , a n x i e ty, 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 box with a shaded border and at least one element in each box with an unshaded border.
Hematologic/Lymphatic/Im m u n o l o g i c E x a m i n a t i o n t c \ l 3 " H e m a t o l o g i c / L y m p h a t i c / I m m u n o l o g i c E x a m i n a t i o n
S y s t e m / B o d y A r e a
E l e m e n t s o f E x a m i n a t i o n
C o n s t i t u t i o n a l
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
H e a d a n d F a c e
P a l p a t i o n a n d / o r p e r c u s s i o n o f f a c e w i t h n o t a t i o n o f p r e s e n c e o r a b s e n c e o f s i n u s t e n d e r n e s s
E y e s
I n s p e c t i o n o f c o n j u n c t i v a e a n d l i d s
E a r s , N o s e , M o u t h a n d T h r o a t
O t o s c o p i c e x a m i n a t i o n o f e x t e r n a l a u d i t o r y c a n a l s a n d t y m p a n i c m e m b r a n e s
I n s p e c t i o n o f n a s a l m u c o s a , s e p t u m a n d t u r b i n a t e s
I n s p e c t i o n o f t e e t h a n d g u m s
E x a m i n a t i o n o f o r o p h a r y n x ( e g , o r a l m u c o s a , h a r d a n d s o f t p a l a t e s , t o n g u e , t o n s i l s , p o s t e r i o r p h a r y n x )
N e c k
E x a m i n a t i o n o f n e c k ( e g , m a s s e s , o v e r a l l a p p e a r a n c e , s y m m e t r y , t r a c h e a l p o s i t i o n , c r e p i t u s )
E x a m i n a t i o n o f t h y r o i d ( e g , e n l a r g e m e n t , t e n d e r n e s s , m a s s )
R e s p i r a t o r y
A s s e s s m e n t o f r e s p i r a t o r y e f f o r t ( e g , i n t e r c o s t a l r e t r a c t i o n s , u s e o f a c c e s s o r y m u s c l e s , d i a p h r a g m a t i c m o v e m e n t )
A u s c u l t a t i o n o f l u n g s ( e g , b r e a t h s o u n d s , a d v e n t i t i o u s s o u n d s , r u b s )
C a r d i o v a s c u l a r
A u s c u l t a t i o n o f h e a r t w i t h n o t a t i o n o f a b n o r m a l s o u n d s a n d m u r m u r s
E x a m i n a t i o n o f p e r i p h e r a l v a s c u l a r s y s t e m b y o b s e r v a t i o n ( e g , s w e l l i n g , v a r i c o s i t i e s ) a n d p a l p a t i o n ( e g , p u l s e s , t e m p e r a t u r e , e d e m a , t e n d e r n e s s )
C h e s t ( B r e a s t s )
G a s t r o i n t e s t i n a l
( A b d o m e n )
E x a m i n a t i o n o f a b d o m e n w i t h n o t a t i o n o f p r e s e n c e o f m a s s e s o r t e n d e r n e s s
E x a m i n a t i o n o f l i v e r a n d s p l e e n
G e n i t o u r i n a r y
L y m p h a t i c
P a l p a t i o n o f l y m p h n o d e s i n n e c k , a x i l l a e , g r o i n , a n d / o r o t h e r l o c a t i o n
M u s c u l o s k e l e t a l
E x t r e m i t i e s
I n s p e c t i o n a n d p a l p a t i o n o f d i g i t s a n d n a i l s ( e g , c l u b b i n g , c y a n o s i s , i n f l a m m a t i o n , p e t e c h i a e , i s c h e m i a , i n f e c t i o n s , n o d e s )
S k i n
I n s p e c t i o n a n d / o r p a l p a t i o n o f 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 box with a shaded border and at least one element in each box with an unshaded border. Musculoskeletal Examinationtc \l3 "Musculoskeletal Examination
System/Body Area
Elements of Examination
Constitutional
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
H e a d a n d F a c e
E y e s
E a r s , N o s e , M o u t h a n d T h r o a t
N e c k
R e s p i r a t o r y
C a r d i o v a s c u l a r
E x a m i n a t i o n o f p e r i p h e r a l v a s c u l a r s y s t e m b y o b s e r v a t i o n ( e g , s w e l l i n g , v a r i c o s i t i e s ) a n d p a l p a t i o n ( e g , p u l s e s , t e m p e r a t u r e , e d e m a , t e n d e r n e s s )
C h e s t ( B r e a s t s )
G a s t r o i n t e s t i n a l
( A b d o m e n )
G e n i t o u r i n a r y
L y m p h a t i c
P a l p a t i o n o f l y m p h n o d e s i n n e c k , a x i l l a e , g r o i n a n d / o r o t h e r l o c a t i o n
M u s c u l o s k e l e t a l
E x a m i n a t i o n o f g a i t a n d s t a t i o n
E x a m i n a t i o n o f j o i n t ( s ) , b o n e ( s ) a n d m u s c l e ( s ) / t e n d o n ( s ) o f f o u r o f t h e f o l l o w i n g s i x a r e a s : 1 ) h e a d a n d n e c k ; 2 ) s p i n e , r i b s a n d p e l v i s ; 3 ) r i g h t u p p e r e x t r e m i t y ; 4 ) l e f t u p p e r e x t r emity;
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
I n s p e c t i o n a n d / o r p a l p a t i o n o f s k i n a n d s u b c u t a n e o u s t i s s u e ( e g , s c a r s , r a s h e s , l e s i o n s , c a f e - a u - l a i t s p o t s , u l c e r s ) i n f o u r o f t h e f o l l o w i n g s i x a r e a s : 1 ) h e a d a n d n e c k ; 2 ) t r u n k ; 3 ) r i g h t u p p e r e x t r e m i t y ; 4 ) l e f t u p p e r e x t r e m i t y ; 5 ) r i g h t l o w e r e x t r e m i ty; 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
T e s t c o o r d i n a t i o n ( e g , f i n g e r / n o s e , h e e l / k n e e / s h i n , r a p i d a l t e r n a t i n g m o v e m e n t s i n t h e u p p e r a n d l o w e r e x t r e m i t i e s , e v a l u a t i o n o f f i n e m o t o r c o o r d i n a t i o n i n y o u n g c h i l d r e n )
E x a m i n a t i o n o f d e e p t e n d o n r e f l e x e s a n d / o r n e r v e s t r e t c h t e s t w i t h n o t a t i o n o f p a t h o l o g i c a l r e f l e x e s ( e g , B a b i n s k i )
E x a m i n a t i o n o f s e n s a t i o n ( e g , b y t o u c h , p i n , v i b r a t i o n , p r o p r i o c e p t i o n )
B r i e f a s s e s s m e n t o f m e n t a l s t a t u s i n c l u d i n g
O r i e n t a t i o n t o t i m e , p l a c e a n d p e r s o n
M o o d a n d a f f e c t ( e g , d e p r e s s i o n , a n x i e t y , a g i t a t i o n)
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 box with a shaded border and at least one element in each box with an unshaded border.
Neurological Examinationtc \l3 "Neur o l o g i c a l E x a m i n a t i o n
S y s t e m / B o d y A r e a
E l e m e n t s o f E x a m i n a t i o n
C o n s t i t u t i o n a l
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
H e a d a n d F a c e
E y e s
O p h t h a l m o s c o p i c e x a m i nation 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)
A u s c u l t a t i o n o f h e a r t w i t h n o t a t i o n o f a b n o r m a l s o u n d s a n d m u r m u r s
E x a m i n a t i o n o f p e r i p h e r a l v a s c u l a r s y s t e m b y o b s e r v a t i o n ( e g , s w e l l i n g , v a r i c o s i t i e s ) a n d p a l p a t i o n ( e g , p u l s e s , t e m p e r a t u r e , e d e m a , t e n d e r n e s s )
C h e s t ( B r e a s t s )
G a s t r o i n t e s t i n a l
( A b d o m e n )
G e n i t o u r i n a r y
L y m p h a t i c
M u s c u l o s k e l e t a l
E x a m i n a t i o n o f g a i t a n d s t a t i o n
A s s e s s m e n t o f m o t o r f u n c t i o n i n c l u d i n g :
M u s c l e s t r e n g t h i n u p p e r a n d l o w e r e x t r e m i t i e s
M u s c l e t o n e i n u p p e r a n d l o w e r e x t r e m i t i e s ( e g , f l a c c i d , c o g w heel, 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)
E x a m i n a t i o n o f s e n s a t i o n ( e g , b y t o u c h , p i n , v i b r a t i o n , p r o p r i o c e p t i o n )
E x a m i n a t i o n o f d e e p t e n d o n r e f l e x e s i n u p p e r a n d l o w e r e x t r e m i t i e s w i t h n o t a t i o n o f p a t h o l o g i c a l r e f l e x e s ( e g , B a b i n s k i )
T e s t c o o r d i n a t i o n ( e g , f i n g e r / n o s e , h e e l / k n e e / s h i n , r a p id alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)
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 i n e a c h b o x w i t h a s h a d e d b o r d e r a n d a t l e a s t o n e e l e m e n t i n e a c h b o x w i t h a n u n s h a d e d b o r d e r .
P s y c h i a t r i c E x a m i n a t i o n t c \ l 3 " P s y c h i a t r i c E x a m i n a t i o n
S y s t e m / B o d y A r e a
E l e m e n t s o f E x a m i n a t i o n
C o n s t i t u t i o n a l
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p atient (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
A s s e s s m e n t o f m u s c l e s t r e n g t h a n d t o n e ( e g , f l a c c i d , c o g w h e e l , s p a s t i c ) w i t h n o t a t i o n o f a n y a t r o p h y a n d a b n o r m a l m o v e m e n t s
E x a m i n a t i o n o f g a i t a n d s t a t i o n
E x t r e m i t i e s
S k i n
N e u r o l o g i c a l
P s y c h i a t r i c
D e s c r i p t i o n o f s p e e c h i n c l u d i n g : r a t e ; v o l u m e ; a r t i c u l a t i o n ; c o h e r e n c e ; a n d s p o n t a n e i t y w i t h n o t a t i o n o f a b n o r m a l i t i e s ( e g , p e r s e v e r a t i o n , p a u c i t y o f l a n g u a g e )
D e s c r i p t i o n o f t h o u g h t p r o c e s s e s i n c l u d i n g : r a t e o f t h o u g h t s ; c o n t e n t o f t h o u g h t s ( e g , l o g i c a l v s . i l l o g i c a l , t a n g e n t i a l ) ; a b s t r a c t r e a s o n i n g ; a n d c o m p u t a t i o n
D e s c r i p t i o n o f a s s o c i a t i o n s ( e g , l o o s e , t a n g e n t i a l , c i r c u m s t a n t i a l , i n t a c t )
D e s c r i p t i o n o f a b n o r m a l o r p s y c h o t i c t h o u g h t s i n c l u d i n g : h a l l u c i n a t i o n s ; d e l u s i o n s ; p r e o c c u p a t i o n w i t h v i o l e n c e ; h o m i c i d a l o r s u i c i d a l i d e a t i o n ; a n d o b s e s s i o n s
D e s c r i p t i o n o f t h e p a t i e n t s j u d g m e n t ( e g , c o n c e r n i n g e v e r y d a y a c t i v i t i e s a n d s o c i a l s i t u a t i o n s ) a n d i n s i g h t ( e g , c o n c e r n i n g p s y c h i a t r i c c o n d i t i o n )
C o m p l e t e m e n t a l s t a t u s e x a m i n a t i o n i n c l u d i n g
O r i e n t a t i o n t o t i m e , p l a c e a n d p e r s on
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 box with a shaded border and at least one element in each box with an unshaded border.
Respiratory Examinationtc \l3 "Respiratory Examination
System/Body Area
Elements of Examination
Constitutional
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
H e a d a n d F a c e
E y e s
E a r s , N o s e , M o u t h a n d T h r o a t
I n s p e c t i o n o f n a s a l m u c o s a , s e p t u m a n d t u r b i n a t e s
I n s p e c t i o n o f t e e t h a n d g u m s
E x a m i n a t i o n o f o r o p h a r y n x ( e g , o r a l m u c o s a , h a r d a n d s o f t p a l a t e s , t o n g u e , t o n s i l s a n d p o s t e r i o r p h a r y n x )
N e c k
E x a m i n a t i o n o f n e c k ( e g , m a s s e s , o v e r a l l a p p e a r a n c e , s y m m e t r y , t r a c h e a l p o s i t i o n , c r e p i t u s )
E x a m i n a t i o n o f t h y r o i d ( e g , e n l a r g e m e n t , t e n d e r n e s s , m a s s )
E x a m i n a t i o n o f j u g u l a r v e i n s ( e g , d i s t e n s i o n ; a , v o r c a n n o n a w a v e s )
R e s p i r a t o r y
I n s p e c t i o n o f c h e s t w i t h n o t a t i o n o f s y m m e t r y a n d e x p a n s i o n
A s s e s s m e n t o f r e s p i r a t o r y e f f o r t ( e g , i n t e r c o s t a l r e t r a c t i o n s , u s e o f a c c e s s o r y m u s c l e s , d i a p h r a g m a t i c m o v e m e n t )
P e r c u s s i o n o f c h e s t ( e g , d u l l n e s s , f l a t n e s s , h y p e r r e s o n a n c e )
P a l p a t i o n o f c h e s t ( e g , t a c t i l e f r e m i t u s )
A u s c u l t a t i o n o f l u n g s ( e g , b r e a t h s o u n d s , a d v e n t i t i o u s s o u n d s , r u b s )
C a r d i o v a s c u l a r
A u s c u l t a t i o n o f h e a r t i n c l u d i n g s o u n d s , a b n o r m a l s o u n d s a n d m u r m u r s
E x a m i n a t i o n o f p e r i p h e r a l v a s c u l a r s y s t e m b y o b s e r v a t i o n ( e g , s w e l l i n g , v a r i c o s i t i e s ) a n d p a l p a t i o n ( e g , p u l s e s , t e m p e r a t u r e , e d e m a , t e n d e r n e s s )
C h e s t ( B r e a s t s )
G a s t r o i n t e s t i n a l
( A b d o m e n )
E x a m i n a t i o n o f a b d o m e n w i t h n o t a t i o n o f p r e s e n c e o f m a s s e s o r t e n d e r n e s s
E x a m i n a t i o n o f l i v e r a n d s p l e e n
G e n i t o u r i n a r y
L y m p h a t i c
P a l p a t i o n o f l y m p h n o d e s i n n e c k , a x i l l a e , g r o i n a n d / o r o t h e r l o c a t i o n
M u s c u l o s k e l e t a l
A s s e s s m e n t o f m u s c l e s t r e n g t h a n d t o n e ( e g , f l a c c i d , c o g w h e e l , s p a s t i c ) w i t h n o t a t i o n o f a n y a t r o p h y a n d a b n o r m a l m o v e m e n t s
E x a m i n a t i o n o f g a i t a n d s t a t i o n
E x t r e m i t i e s
I n s p e c t i o n a n d p a l p a t i o n o f d i g i t s a n d n a i l s ( e g , c l u b b i n g , c y a n o s i s , i n f l a m m a t i o n , p e t e c h i a e , i s c h e m i a , i n f e c t i o n s , n o d e s )
S k i n
I n s p e c t i o n a n d / o r p a l p a t i o n o f s k i n a n d s u b c u t a n e o u s t i s s u e ( e g , r a s h e s , l e s i o n s , u l c e r s )
N e u r o l o g i c a l /
P s y c h i a t r i c
B r i e f a s s e s s m e n t o f m e n t a l s t a t u s i n c l u d i n g
O r i e n t a t i o n t o t i m e , p l a c e a n d p e r s o n
M o o d a n d a f f e c t ( e g , 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 box with a shaded border and at least one element in each box with an unshaded border.
Skin Ex a m i n a t i o n t c \ l 3 " S k i n E x a m i n a t i o n
S y s t e m / B o d y A r e a
E l e m e n t s o f E x a m i n a t i o n
C o n s t i t u t i o n a l
M e a s u r e m e n t o f a n y t h r e e o f t h e f o l l o w i n g s e v e n v i t a l s i g n s : 1 ) s i t t i n g o r s t a n d i n g b l o o d p r e s s u r e , 2 ) s u p i n e b l o o d p r e s s u r e , 3 ) p u l s e r a t e a n d r e g u l a r i t y , 4 ) r e s p i r a t i o n ,
5 ) t e m p e r a t u r e , 6 ) h e i g h t , 7 ) w e i g h t ( M a y b e m e a s u r e d a n d r e c o r d e d b y a n c i l l a r y s t a f f )
G e n e r a l a p p e a r a n c e o f p a t i e n t ( e g , d e v e l o p m e n t , n u t r i t i o n , b o d y h a b i t u s , d e f o r m i t i e s , a t t e n t i o n t o g r o o m i n g )
H e a d a n d F a c e
E y e s
I n s p e c t i o n o f c o n j u n c t i v a e a n d l i d s
E a r s , N o s e , M o u t h
a n d T h r o a t
I n s p e c t i o n o f l i p s , t e e t h a n d g u m s
E x a m i n a t i o n o f o r o p h a r y n x ( e g , o r a l m u c o s a , h a r d a n d s o f t p a l a t e s , t o n g u e , t o n s i l s , p o s t e r i o r p h a r y n x )
N e c k
E x a m i n a t i o n o f t h y r o i d ( e g , e n l a r g e m e n t , t e n d e r n e s s , m a s s )
R e s p i r a t o r y
C a r d i o v a s c u l a r
E x a m i n a t i o n o f p e r i p h e r a l v a s c u l a r s y s t e m b y o b s e r v a t i o n ( e g , s w e l l i n g , v a r i c o s i t i e s ) a n d p a l p a t i o n ( e g , p u l s e s , t e m p e r a t u r e , e d e m a , t e n d e r n e s s )
C h e s t ( B r e a s t s )
G a s t r o i n t e s t i n a l
( A b d o m e n )
E x a m i n a t i o n o f l i v e r a n d s p l e e n
E x a m i n a t i o n o f a n u s f o r c o n d y l o m a a n d o t h e r l e s i o n s
G e n i t o u r i n a r y
L y m p h a t i c
P a l p a t i o n o f l y m p h n o d e s i n n e c k , a x i l l a e , g r o i n a n d / o r o t h e r l o c a t i o n
M u s c u l o s k e l e t a l
E x t r e m i t i e s
I n s p e c t i o n a n d p a l p a t i o n o f d i g i t s a n d n a i l s ( e g , c l u b b i n g , c y a n o s i s , i n f l a m m a t i o n , p e t e c h i a e , i s c h e m i a , i n f e c t i o n s , n o d e s )
S k i n
P a l p a t i o n o f s c a l p a n d i n s p e c t i o n o f h a i r o f s c a l p , e y e b r o w s , f a c e , c h e s t , p u b i c a r e a ( w h e n i n d i c a t e d ) a n d e x t r e m i t i e s
I n s p e c t i o n a n d / o r p a l p a t i o n o f s k i n a n d s u b c u t a n e o u s t i s s u e ( e g , r a s h e s , l e s i o n s , u l c e r s , s u s c e p t i b i l i t y t o a n d p r e s e n c e o f p h o t o d a m a g e ) i n e i g h t o f t h e f o l l o w i n g t e n a r e a s :
H e a d , i n c l u d i n g t h e f a c e a n d
N e c k
C h e s t , i n c l u d i n g b r e a s t s a n d a x i l l a e
A b d o m e n
G e n i t a l i a , g r o i n , b u t t o c k s
B a c k
R i g h t u p p e r e x t r e m i t y
L e f t u p p e r e x t r e m i t y
R i g h t l o w e r e x t r e m i t y
L e f t l o w e r e x t r e m i t y
N O T E : F o r t h e c o m p r e h e n s i v e l e v e l , t h e e x a m i n a t i o n o f a t l e a s t e i g h t a n a t o m i c a r e a s m u s t b e p e r f o r m e d a n d d o c u m e n t e d . F o r t h e t h r e e l o w e r l e v e l s o f e x a m i n a t i o n , e a c h b o d y a r e a i s c o u n t e d s e p a r a t e l y . F o r e x a m p l e , i n s p e c t i o n a n d / o r p a l p a t i o n o f t h e s k i n a n d s u b c u t a n e o u s t i s s u e o f t h e r i g h t u p p e r e x t r e m i t y a n d t h e l e f t u p p e r e x t r e m i t y c o n s t i t u t e s t w o e l e m e n t s .
I n s p e c t i o n o f e c c r i n e a n d a p o c r i n e g lands 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 box with a shaded border and at least one element in each box with an unshaded border.
C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKINGtc \l1 "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 OPTIONStc \l2 "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 REVIEWEDtc \l2 "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.
DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, should be documented.
DG: The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as "WBC elevated" or "chest x-ray unremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results.
DG: A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.
DG: Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of Old records reviewed or additional history obtained from family without elaboration is insufficient.
DG: The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented.
DG: The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented.
RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITYtc \l2 "RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.
DG: Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.
DG: If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of the E/M encounter, the type of procedure, eg, laparoscopy, should be documented.
DG: If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.
DG: The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.
The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.
TABLE OF RISKtc \l2 "TABLE OF RISK
Level of
Risk
Presenting Problem(s)
Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
One self-limited or minor problem, eg, cold, insect bite, tinea corporis
Laboratory tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound, eg, echocardiography
KOH prep
Rest
Gargles
Elastic bandages
Superficial dressings
Low
Two or more self-limited or minor problems
One stable chronic illness, eg, well controlled hypertension, non-insulin dependent diabetes, cataract, BPH
Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain
Physiologic tests not under stress, eg, pulmonary function tests
Non-cardiovascular imaging studies with contrast, eg, barium enema
Superficial needle biopsies
Clinical laboratory tests requiring arterial puncture
Skin biopsies
Over-the-counter drugs
Minor surgery with no identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives
Moderate
One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis, eg, lump in breast
Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis
Acute complicated injury, eg, head injury with brief loss of consciousness
Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test
Diagnostic endoscopies with no identified risk factors
Deep needle or incisional biopsy
Cardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram, cardiac catheterization
Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis
Minor surgery with identified risk factors
Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or dislocation without manipulation
High
One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure
An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory loss
Cardiovascular imaging studies with contrast with identified risk factors
Cardiac electrophysiological tests
Diagnostic Endoscopies with identified risk factors
Discography
Elective major surgery (open, percutaneous or endoscopic) with identified risk factors
Emergency major surgery (open, percutaneous or endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate or to de-escalate care because of poor prognosis D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CAREtc \l1 "DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.
DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.
PAGE 5
General Multi-System Pg PAGE of 5 PAGE
Cardiovascular Pg PAGE of 2 PAGE
Ear, Nose and Throat Pg PAGE of 3 PAGE
Eye Pg PAGE of 2 PAGE
Genitourinary Pg PAGE of 4 PAGE
Hematologic/Lymphatic/Immunologic Pg PAGE of 2 PAGE
Musculoskeletal Pg PAGE of 3 PAGE
Neurologic Pg PAGE of 3 PAGE
Psychiatric Pg PAGE of 2 PAGE
Respiratory Pg PAGE of 2 PAGE
Skin Pg PAGE of 2 PAGE
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