- 1 -

11th

12th

- 2 -

2nd

- 3 -

3rd

- 4 -

4th

- 5 -

5th

- 6 -

6th

- 7 -

7th

- 8 -

8th

- 9 -

9th

- A -

Adnexa/parametria

IconGeneral Multi-System Examination
IconGenitourinary Exam

Adnexae

Allergic/Immunologic

AMA

IconWelcome
IconForward

American Medical Association

IconWelcome
IconForward

Amount and/or

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

And/or Mortality

IconTable of Contents
IconDocumentation of the Complexity of Medical Decision Making

And/or Social History

Anisocoria

Apocrine

Appropriateness

Area/system

Areas/systems

Areas/systems OR

Assistance

representatives

Asymptomatic

- B -

Babinski

IconGeneral Multi-System Examination
IconMusculoskeletal Exam
IconNeurological Exam

Be Reviewed

BPH

Bromhidrosis

- C -

C/D

IconGeneral Multi-System Examination
IconEye Exam
IconNeurological Exam

Cafe-au-lait

Cardiac electrophysiological

Cardiovascular  Examination

IconTable of Contents
IconCardiovascular Exam

Catheterization

CC

IconTable of Contents
IconDocumentation of History

Chief Complaint

IconTable of Contents
IconDocumentation of History

Choanae

Chromhidroses

Coarctation

Comorbidities

Comorbidities/underlying

Complexity

Medical Decision Making

Components--history

Comprehensive

Comprehensive Examination--should

Condyloma

Cont’d

CONTENT AND DOCUMENTATION REQUIREMENTS

Contraindicated

Coordination

Counseling

IconTable of Contents
IconDocumentation of Counseling or Coordination of Care

CPT

IconForward
IconGeneral Principals of Documentation
IconDocumentation of E&M Services
IconDocumentation of Examination

CPT Advisory Committees

CPT Editorial Panel

Crepitation

IconGeneral Multi-System Examination
IconMusculoskeletal Exam

Crepitus

IconGeneral Multi-System Examination
IconEar, Nose, and Throat Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconRespiratory Exam

Culdocentesis

Cystocele

IconGeneral Multi-System Examination
IconGenitourinary Exam

- D -

Detailed

Detailed Examination--examinations

Detailed Examination--should

DG

IconDocumentation of E&M Services
IconDocumentation of History
IconDocumentation of Examination
IconDocumentation of the Complexity of Medical Decision Making
IconDocumentation of Counseling or Coordination of Care

Diagnoses

Diagnostic endoscopies

Diagnostic Procedure

Do Payers Want

Document

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Documentation Guidelines

IconWelcome
IconIntroduction

DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE

DOCUMENTATION OF E/M SERVICES

DOCUMENTATION OF EXAMINATION

DOCUMENTATION OF HISTORY

DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING

Documentation Requirements

IconTable of Contents
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Domiciliary

IconDocumentation of E&M Services
IconDocumentation of History

- E -

E.g

E/M

level

IconDocumentation of E&M Services
IconDocumentation of History
IconDocumentation of the Complexity of Medical Decision Making
IconDocumentation of Counseling or Coordination of Care

levels

providing

These Documentation Guidelines

E/M Services

Ear

Ears, Nose

IconTable of Contents
IconDocumentation of History
IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Ecchymoses

Eccrine

Echocardiography

Eg

IconDocumentation of E&M Services
IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam
IconDocumentation of the Complexity of Medical Decision Making

EKG/EEG

Encounter Dominated

Endoscopic

Epididymides

Eustachian

Evaluation

IconWelcome
IconForward
IconGeneral Principals of Documentation

Exam

Level

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Examination

IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Examination10

Expanded Problem Focused

IconDocumentation of History
IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Expanded Problem Focused Examination-should

Expanded Problem Focused Examination--should

Extremitites

Exudates

IconGeneral Multi-System Examination
IconEye Exam
IconNeurological Exam

Eye Examination

IconTable of Contents
IconEye Exam

- F -

Face

IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

FAMILY AND/OR SOCIAL HISTORY

FEMALE

IconGeneral Multi-System Examination
IconGenitourinary Exam

Finger/nose

IconMusculoskeletal Exam
IconNeurological Exam

Floor/unit

FOR EVALUATION AND MANAGEMENT SERVICES

FOREWORD

Fremitus

IconGeneral Multi-System Examination
IconRespiratory Exam

Fundi

- G -

Gastrointestinal

IconWelcome
IconDocumentation of History
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

General Multi-System Examination

IconTable of Contents
IconGeneral Multi-System Examination

GENERAL MULTI-SYSTEM EXAMINATIONS

GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

Genitourinary Examination

IconTable of Contents
IconGenitourinary Exam

- H -

Habitus

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

HCFA

IconWelcome
IconForward

Health Care Financing Administration

IconWelcome
IconForward

Heel/knee/shin

Hematologic/Lymphatic

Hematologic/Lymphatic/Immunologic

Hematologic/Lymphatic/Immunologic Examination

IconTable of Contents
IconHematologic/Lymphatic/Immunologic Exam

High Complexity

His/her

History

Type

HISTORY OF PRESENT ILLNESS

HPI

IconTable of Contents
IconDocumentation of E&M Services
IconDocumentation of History

Hydrocele

Hyperhidrosis

Hyperresonance

IconGeneral Multi-System Examination
IconRespiratory Exam

Hypomania

- I -

ICD-9-CM

Important

Incisional

Including

pneumo-otoscopy

Inspection and/or

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconRespiratory Exam
IconSkin Exam

Intraocular

INTRODUCTION

Is Documentation

Ischemia

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconHematologic/Lymphatic/Immunologic Exam
IconRespiratory Exam
IconSkin Exam

- K -

Knee/shin

KOH

Kyphosis

- L -

Lacrimal

Lagophthalmos

Laparoscopy

Level

E/M

IconDocumentation of E&M Services
IconDocumentation of History
IconDocumentation of Examination
IconDocumentation of the Complexity of Medical Decision Making
IconDocumentation of Counseling or Coordination of Care

Exam

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Low Complexity

Luxation

IconGeneral Multi-System Examination
IconMusculoskeletal Exam

- M -

Making--appear

MALE

IconGeneral Multi-System Examination
IconGenitourinary Exam

Management

IconWelcome
IconForward
IconGeneral Principals of Documentation

Management Options

IconTable of Contents
IconDocumentation of the Complexity of Medical Decision Making

Measurement

Medical Decision Making

Complexity

Medical Record Documentation

General Principles

Medicare Contractor Medical Directors

MI

Mirror

nasopharynx

Moderate Complexity

Morbidity

IconTable of Contents
IconDocumentation of the Complexity of Medical Decision Making

Mouth

IconDocumentation of History
IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Mucosa

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconHematologic/Lymphatic/Immunologic Exam
IconRespiratory Exam
IconSkin Exam

Mucosal

Musculoskeletal

IconDocumentation of History
IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Musculoskeletal Examination

IconTable of Contents
IconMusculoskeletal Exam

- N -

N/A

Nasopharynx

mirror

Neurologic

IconGeneral Multi-System Examination
IconDocumentation of the Complexity of Medical Decision Making

Neurological Examination

IconTable of Contents
IconNeurological Exam

Nodularity

IconGeneral Multi-System Examination
IconGenitourinary Exam

Non-cardiovascular

None

Nose

NOTE

IconMusculoskeletal Exam
IconSkin Exam

November

Number

Diagnoses

NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS

- O -

Old

Ophthalmoscopic

IconGeneral Multi-System Examination
IconEye Exam
IconNeurological Exam

Organomegaly

IconGeneral Multi-System Examination
IconGenitourinary Exam

Oropharynx

IconGeneral Multi-System Examination
IconEar, Nose, and Throat Exam
IconHematologic/Lymphatic/Immunologic Exam
IconRespiratory Exam
IconSkin Exam

Osler’s

Otoscopic

IconGeneral Multi-System Examination
IconEar, Nose, and Throat Exam
IconHematologic/Lymphatic/Immunologic Exam

Over-the-counter

- P -

Palpation and/or

IconEar, Nose, and Throat Exam
IconHematologic/Lymphatic/Immunologic Exam

Palpebral

Parenteral

PAST

Past, Family

Past, Family and/or Social History

Patient’s

IconDocumentation of Examination
IconGeneral Multi-System Examination
IconPsychiatric Exam

Percutaneous

Petechiae

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconHematologic/Lymphatic/Immunologic Exam
IconRespiratory Exam
IconSkin Exam

PFSH

ROS and/or

Physician/patient and/or

Pneumonitis

Pneumo-otoscopy

including

Practicing Physicians Advisory Council

Preauricular

Present Illness

IconTable of Contents
IconDocumentation of History

Presenting

Problem

Problem

Presenting

Problem Focused

IconDocumentation of History
IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Problem Focused Examination-should

Problem Focused Examination--should

Problem Pertinent

Proprioception

IconGeneral Multi-System Examination
IconMusculoskeletal Exam
IconNeurological Exam

Providing

E/M

Psychiatric Examination

IconTable of Contents
IconPsychiatric Exam

Ptosis

Pyelonephritis

Pyriform

- R -

R/O

Rectocele

IconGeneral Multi-System Examination
IconGenitourinary Exam

Refer

CPT

Representatives

assistance

Respiratory  Examination

IconTable of Contents
IconRespiratory Exam

Retractability

Review

Systems

IconTable of Contents
IconDocumentation of History

REVIEW OF SYSTEMS

Risk

Significant Complications

Table

RISK OF SIGNIFICANT COMPLICATIONS

ROS

IconTable of Contents
IconDocumentation of History

ROS and/or

PFSH

ROS and/or PFSH

- S -

S

IconDocumentation of History
IconDocumentation of Examination
IconMusculoskeletal Exam
IconDocumentation of the Complexity of Medical Decision Making

S3

S4

Scoliosis

See musculoskeletal

IconMusculoskeletal Exam
IconNeurological Exam

Significant Complications

Risk

Single Organ System Examinations

IconTable of Contents
IconDocumentation of Examination

Skin Examination

IconTable of Contents
IconSkin Exam

Spermatocele

Spleen

Straightforward

Straight-forward

Stroma

Subluxation

IconGeneral Multi-System Examination
IconMusculoskeletal Exam

System/area

System/Body Area

IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Systems

Review

IconTable of Contents
IconDocumentation of History

- T -

Table

Risk

TABLE OF CONTENTS

TABLE OF RISK

Tardive dyskinesia

Testing

Ther

These Documentation Guidelines

E/M

Thoracentesis

Throat

IconDocumentation of History
IconDocumentation of Examination
IconGeneral Multi-System Examination
IconCardiovascular Exam
IconEar, Nose, and Throat Exam
IconEye Exam
IconGenitourinary Exam
IconHematologic/Lymphatic/Immunologic Exam
IconMusculoskeletal Exam
IconNeurological Exam
IconPsychiatric Exam
IconRespiratory Exam
IconSkin Exam

Throat Examination

IconTable of Contents
IconEar, Nose, and Throat Exam

Thrombolytic

TIA

Tinea corporis

Treating

and/or

Turbinates

IconGeneral Multi-System Examination
IconEar, Nose, and Throat Exam
IconHematologic/Lymphatic/Immunologic Exam
IconRespiratory Exam

Type

History

- U -

Ultrasound, eg

Urethral meatus

- W -

Waveform

WBC

WHAT DO PAYERS WANT AND WHY

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT

Why

Why Is

- X -

Xanthelasma

Xanthomas