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FAQ #18
What exactly is required for a comprehensive exam using the 1995 E/M guidelines vs. the 1997 rules?
Answer: The answer is known.
The physician may choose to use the 1995 or the 1997 E/M guidelines when completing their documentation
The 1995 Comprehensive Physcial Exam
The 1995 E/M guidelines define a comprehensive physical exam as:
- Comprehensive Exam-- a general multi-system examination or complete examination of a
single organ system.
(1995 E/M guidleines: p. 9)
This is kind of vague. However, on the next page, the comprehensive exam is defined in more precise terms:
- The medical record for a general multi-system examination should include
findings about 8 or more of the 12 organ systems.
(1995 E/M guidelines: p. 10)
So that's that.
The 1997 Comprehensive Physical Exam
The 1997 E/M guidelines define a general multi-system comprehensive physical exam as:
- 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.
(1997 E/M guidelines: p. 12)
The 1997 E/M guidelines also contain the following specialty-specific exams
(1997 E/M guidelines: pp. 19 - 47)
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