The levels of Evaluation and Management (E/M) services are based on four types of examination that are defined as follows:

• 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 other symptomatic or related organ system(s).
• 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.

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