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PHYSICAL EXAM
 

 

The physical exam is one of the three key components of E/M documentation. Similar to the levels of history, there are four levels of physical exam documentation:

1)    Problem Focused
2)    Expanded Problem Focused
3)    Detailed
4)    Comprehensive

E/M University Coding Tip: Unlike the key components of history and medical decision-making, the rules defining the various levels of physical exam are quite different for the 1995 vs. the 1997 E/M guidelines. The 1995 E/M guidelines allow the physician to complete the physical exam by documenting organ systems or body areas. This approach is quite subjective and gives physicians a lot of leeway and “wiggle room.” On the other hand, the 1997 E/M guidelines are quite rigid and force physicians to document the exam using specific bullets. The 1997 physical exam rules are much more “black and white”—either the bullets are there or they aren’t.

1997 Physical Exam Rules

General Multi-System Exam (for specialty exams, click here.)

For the purposes of documenting the physical exam, the 1997 E/M guidelines rely on the use of bullets from well defined organ systems:

1997 Problem Focused Exam

One to five bullets from one or more organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: CTA
CV: RRR, no MRGs

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)

Total bullets = four (although only one to five bullets are required)

1997 Expanded Problem Focused Exam

At least six bullets from any organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, nontender
Extremities: No peripheral edema

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for examination of the abdomen)
(1 bullet for examination of extremities for edema)

Total bullets = six

1997 Detailed Exam
At least two bullets from six organ systems OR 12 bullets from two or more organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)

Total bullets = 12

1997 Comprehensive Exam

Two bullets from EACH of nine organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA
HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations;
normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules
Psych: Appropriate affect, alert and oriented to person, place and time

Systems and Bullets

Constitutional
(1 bullet for three vital signs)
(1 bullet for general appearance)

Eyes
(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)

Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose—“atraumautic”)
(1 bullet for examination of oropharynx)

Neck
(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)

Respiratory
(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)

Cardiovascular
(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)

Gastrointestinal
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)

Lymphatic
(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)

Skin
(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)

Psychiatric
(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)

Total systems = 10 (although only nine are required)
Total bullets = 20 (although only 18 are required—two in EACH of nine systems)

E/M University Coding Tip: Although it may seem tedious at first, it is recommended that physicians use the 1997 bullet points when quantifying the physical exam. The best approach is to review the organ systems and bullets and construct a pre-set template for each level of exam. This will ensure optimal compliance with the somewhat arbitrary rules for documenting the exam.

Organ Systems

The 1997 E/M guidelines recognize the following organ systems:

1. Constitutional
2. Eyes
3. Ears, nose, mouth and throat
4. Neck
5. Respiratory
6. Cardiovascular
7. Chest (breasts)
8. Gastrointestinal (abdomen)
9. Genitourinary (male)
10.Genitourinary (female)
11. Lymphatic
12. Musculoskeletal
13. Skin
14. Neurologic
15. Psychiatric

Physical Exam Bullets

Constitutional

    1)   Three vital signs
   2)    General appearance

Eyes

    1)   Inspection of conjunctivae and lids
    2)   Examination of pupils and irises (PERRLA)
    3)   Ophthalmoscopic discs and posterior segments

Ears, Nose, Mouth, and Throat

    1)   External appearance of the ears and nose (overall appearance, scars, lesions, masses)
    2)   Otoscopic examination of the external auditory canals and tympanic membranes
    3)   Assessment of hearing
    4)   Inspection of nasal mucosa, septum and turbinates
    5)   Inspection of lips, teeth and gums
    6)   Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx


Neck

    1)   Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
    2)   Examination of thyroid

Respiratory

    1)   Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
    2)   Percussion of chest (e.g., dullness, flatness, hyperresonance)
    3)   Palpation of chest (e.g., tactile fremitus)
    4)   Auscultation of the lungs

Cardiovascular

    1)   Palpation of the heart (location, size, thrills)
    2)   Auscultation of the heart with notation of abnormal sounds and murmurs
    3)    Assessment of lower extremities for edema and/or varicosities
    4)   Examination of the carotid arteries (e.g., pulse amplitude, bruits)
    5)   Examination of abdominal aorta (e.g., size, bruits)
    6)   Examination of the femoral arteries (e.g., pulse amplitude, bruits)
    7)    Examination of the pedal pulses (e.g., pulse amplitude)

Chest (Breasts)

    1)   Inspection of the breasts (e.g., symmetry, nipple discharge)
    2)   Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)

Gastrointestinal (Abdomen)

    1)   Examination of the abdomen with notation of presence of masses or tenderness
    2)   Examination of the liver and spleen
    3)   Examination for the presence or absence of hernias
    4)   Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids,
           rectal masses
    5)   Obtain stool for occult blood testing when indicated

Genitourinary (Male)

    1)    Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)
    2)   Examination of the penis
    1)   Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness)

Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures, which may include:

    1)   Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)
    2)   Examination of the urethra (e.g., masses, tenderness, scarring)
    3)    Examination of the bladder (e.g., fullness, masses, tenderness)
    4)   Examination of the cervix (e.g., general appearance, discharge, lesions)
    5)   Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
    6)    Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

Lymphatic

Palpation of lymph nodes two or more areas:

    1)   Neck
    2)    Axillae
    3)    Groin
    4)   Other

Musculoskeletal

    1)   Examination of gait and station
    2)   Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia,           infections, nodes)

Examination of the joints, bones, and muscles of one or more of the following six areas:

    a)   head and neck
    b)    spine, ribs, and pelvis
    c)    right upper extremity
    d)   left upper extremity
    e)   right lower extremity
    f)    left lower extremity

The examination of a given area may include:

 1)   Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation,
 2)   defects, tenderness, masses or effusions
3)   Assessment of range of motion with notation of any pain, crepitation or contracture
 4)  Assessment of stability with notation of any dislocation, subluxation, or laxity
 5)  Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any  atrophy or abnormal movements

Skin

    1)   Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
   2)   Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

Neurologic

    1)    Test cranial nerves with notation of any deficits
    2)   Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)
    3)   Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

    1)   Description of patient’s judgment and insight

Brief assessment of mental status which may include

   1)   orientation to time, place, and person
   2)   recent and remote memory
   3)   mood and affect

E/M University Coding Tip: the 1995 physical exam rules may seem appealing, but they are too vague and subjective to be relied upon to withstand a systematic audit. It is recommended that physicians utilize the more concrete 1997 physical exam rules (see above)

1997 Specialty Exams

1995 Physical Exam Rules

For the purposes of documenting the physical exam, the 1995 E/M guidelines recognize the following body areas and organ systems:

Body Areas

   1)   Head, including the face
   2)   Neck
   3)   Chest, including breasts and axillae
   4)   Abdomen
   5)   Genitalia, groin, buttocks
   6)   Back, including spine
   7)   Each extremity

Organ Systems

   1)   Constitutional (e.g., vital signs, general appearance)
   2)   Eyes
   3)   Ears, nose, mouth and throat
   4)   Cardiovascular
   5)   Respiratory
   6)   Gastrointestinal
   7)   Genitourinary
   8)   Musculoskeletal
   9)   Skin
 10)   Neurologic
 11)   Psychiatric
 12)   Hematologic/lymphatic/immunologic

Using the 1995 E/M guidelines, the various levels of physical exam are defined as follows:

Problem Focused—a limited examination of the affected body are or organ system

Expanded Problem Focused—a limited examination of the affected body area or organ system and other symptomatic or related organ systems

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

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