The 1997 documentation guidelines are significantly different from the 1995 Documentation Guidelines. Either set of guidelines can be performed by any physician, regardless of specialty. When documenting these examinations, each element must satisfy any numeric requirements (such as “Measurement of any three of the following seven”) included in the description of the element. Elements with multiple components but with no specific numeric requirement (such as “Examination of liver and spleen”) require documentation of at least one component. Documentation beyond the required elements should be documented with findings related to the additional systems and/or areas.

Example:

  • Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is not sufficient.
  • Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
  • A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

The levels of Evaluation and Management (E/M) services are based on four types of examination for the 1997 guidelines general multi-system are:

  • Problem Focused: 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).
  • Expanded Problem Focused: Should include performance and documentation of at least six elements identified by a bullet in one or more organ system(s) or body area(s).
  • Detailed: 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 system(s) or body area(s).
  • Comprehensive: Should include at least nine organ systems of 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.

Single Organ System Examination Level of Service

Exam Type

Description

Problem Focused

Should include performance and documentation of one to five elements identified by a bullet, whether in a box with a shaded or unshaded border.

Expanded Problem Focused

Should include performance and documentation of at least six elements identified by a bullet, whether in a box with a shaded or unshaded border.

Detailed

Examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet, whether in box with a shaded or unshaded border.

Comprehensive

Should include performance of all elements identified by a bullet, whether in box with a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.

An examination may involve several organ systems or a single organ system. The type and extent of the examination performed is based upon clinical judgment, the patient’s history and nature of the presenting problem. We have listed for example a Cardiovascular Examination for the single organ specialty exam. Visit the Centers for Medicare and Medicaid Services (CMS) website for the general multi-system examination. Download the full listing of specialty exams in the 1997 Documentation Guidelines for Evaluation and Management Services.

Cardiovascular Examination Single Organ Specialty Exam

Exam Type

Description

Constitutional

Measurement of any three of seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight
General appearance of patient (i.e. development, nutrition, body habitus deformities, attention to grooming)

Head and Face

Inspection of conjunctivae and lids (i.e. xanthelasma)

Ear, Nose, Mouth and Throat

Inspection of teeth, gums and palate
Inspection of oral mucosa with notation of presence of pallor or cyanosis

Neck

Examination of jugular veins (i.e. distension; a, v or cannon a waves)
Examination of thyroid (i.e. enlargement, tenderness, mass)

Respiratory

Assessment of respiratory effort (i.e. intercostal retractions, use of accessory muscles, diaphragmatic movement)
Auscultation of lungs (i.e. breath sounds, adventitious sounds, rubs)

Cardiovascular

Palpation of heart (i.e. location, size, and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4)
Auscultation of heart including sounds and murmurs
Measurement of blood pressure in two or more extremities when indicated (i.e. aortic dissection, coarctation)
Examination of:
Carotid arteries (i.e. waveforms, pulse amplitude, bruits, apical-carotid delay))
Abdominal aorta (i.e. size, bruits)
Femoral arteries (i.e. pulse amplitude, bruits)
Pedal pulses (i.e. pulse amplitude)
Extremities for peripheral edema and/or varicosities

Chest (Breasts)

 

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence or masses or tenderness
Examination of liver and spleen
Obtain stool sample for occult blood test when indicated

Genitourinary (Abdomen)

 

Lymphatic

 

Musculoskeletal

Examination of the back with notation of kyphosis or scoliosis
Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs
Assessment of muscle strength and tone (i.e. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Extremities

Inspection and palpation of digits and nails (i.e. clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler’s nodes)

Skin

Inspection and /or palpation of skin and subcutaneous tissue (i.e. stasis dermatitis, ulcers, scars, xanthomas)

Neurologic/ Psychiatric

Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (i.e. Babinski)
Examination of sensation (i.e. by touch, pin, vibration, proprioception)