|
FAQ #21
What exactly is required for a problem focused 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 Problem Focused Physcial Exam
The 1995 E/M guidelines define a problem focused physical exam as:
- Problem Focused -- a limited examination of the affected body area or organ system.
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)
Although this is kind of vague compared to the 1997 exam rules, it is pretty clear that all you need to do is examine one body area or organ system. It would be difficult NOT to qualify for this exam even if you tried.
The 1997 Problem Focused Physical Exam
The 1997 E/M guidelines define a problem focused physical exam as:
- 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).
(1997 E/M guidelines: p. 11)
So, if you document at least ONE bullet from any organ systems, you have completed a problem focused 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 ONE bullet must be recorded.
The 1997 E/M guidelines also contain the following specialty-specific exams
(1997 E/M guidelines: pp. 19 - 47) |
