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B. DOCUMENTATION OF EXAMINATION
The levels of E/M services are based on four types of examination:
· 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 any ther symptomatic or related body area(s) or organ system(s).
· Detailed -- an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
· Comprehensive -- a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).
These types of examinations have been defined for general multi-system and the following single organ systems:
· Cardiovascular
· Ears, Nose, Mouth and Throat
· Eyes
· Genitourinary (Female)
· Genitourinary (Male)
· Hematologic/Lymphatic/Immunologic
· Musculoskeletal
· Neurological
· Psychiatric
· Respiratory
· Skin
A general multi-system examination or a single organ system examination may be performed by any physician regardless of specialty. The type (general multi-system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgement, the patient’s history, and the nature of the presenting problem(s).
The content and documentation requirements for each type and level of examination are summarized below and described in detail in tables beginning on page 13. In the tables, organ systems and body areas recognized by CPT for purposes of describing examinations are shown in the left column. The content, or individual elements, of the examination pertaining to that body area or organ system are identified by bullets (·) in the right column.
Parenthetical examples, “(eg, ...)”, have been used for clarification and to provide guidance regarding documentation. Documentation for 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. It is possible for a given examination to be expanded beyond what is defined here. When that occurs, findings related to the additional systems and/or areas should be documented.
•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 any 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).
GENERAL MULTI-SYSTEM EXAMINATIONS
General multi-system examinations are described in detail beginning on page 13. To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:
· Problem Focused Examination-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 Examination-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 Examination--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 systems or body areas.
· Comprehensive Examination--should include at least nine organ systems or 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 EXAMINATIONS
The single organ system examinations recognized by CPT are described in detail beginning on page 18. Variations among these examinations in the organ systems and body areas identified in the left columns and in the elements of the examinations described in the right columns reflect differing emphases among specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met:
· Problem Focused Examination--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 Examination--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 Examination--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.
Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (·), whether in a box with a shaded or unshaded border.
· Comprehensive Examination--should include performance of all elements identified by a bullet (·), whether in 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.
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