Documentation Of Examination

B.     DOCUMENTATION OF EXAMINATION

The levels of E/M services are based on four types of examination that are defined as follows:

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

The extent of examinations performed and documented is dependent upon clinical judgement and the nature of the presenting problem(s).  They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

•DG:    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 insufficient.

•DG:    Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described.

•DG:    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).

•DG:    The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.