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FAQ #19
What exactly is required for a detailed exam using the 1995 E/M guidelines vs. the 1997 rules?
Answer: The answer is known (kind of).
The physician may choose to use the 1995 or the 1997 E/M guidelines when completing their documentation
The 1995 Detailed Physcial Exam
The 1995 E/M guidelines define a detailed physical exam as:
- Detailed -- an extended examination of the affected body area(s) and other symptomatic
or related organ system(s).
For purposes of 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 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
(1995 E/M guidleines: p. 9)
This is kind of vague. For example, what is meant by and "extended" exam? Indeed, the word "extended" is all that separates a detailed exam from an expanded problem focused exam when using the1995 E/M guidelines (see FAQ 20). And how do you decide what the "affected body area(s)" are? If a patient has renal failure, what are the affected body areas and organ systems? I have no idea. Apparently, it is up to each examiner to decide.
Some institutions have (such as Tulane Medical School) have defined the detailed exam a little more precisely, saying that a detailed exam requires an extended exam of TWO to SEVEN organ systems or body areas. Again, the key word seems to be "extended," but it is not defined in this context.
Tulane solves the riddle of how to tell an expanded problem focused exam from a detailed exam in the following way:
"When 2-7 exam elements are documented, the reviewer determines whether the exam is Expanded Problem Focused or Detailed based on the documentation of the other E/M Key Components (History and Medical Decision Making)."
Tulane University Medical Group: Documenting the Physical Exam
The 1997 Detailed Physical Exam
The 1997 E/M guidelines define a detailed physical exam as:
- 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.
(1997 E/M guidelines: p. 12)
So, if you document at least 12 bullets from any organ systems, you have completed a detailed physical exam according to the 1997 E/M guidelines
You may also choose to complete a detailed exam using any of the specialty exams below. In all cases, at least 12 bullets must be recorded.
The 1997 E/M guidelines also contain the following specialty-specific exams
(1997 E/M guidelines: pp. 19 - 47) |
