Examination Component of 1995 and 1997 Documentation Guidelines

As stated in previous articles, there are two versions of the documentation guidelines – the 1995 version and the 1997 version. The most substantial differences between the two versions occur in the examination documentation section.

The extent of examinations performed and documented is dependent upon clinical judgment 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.

1995 Guidelines

The levels of evaluation and management (E/M) services are based on four types of examinations 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

The chart below reflects the specific documentation requirements for each examination type.   

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

A general multi-system examination refers to "eight or more" body areas or organ systems.

The 1997 "comprehensive" single organ system examination may be used as guidance when selecting an examination based on the 1995 "complete examination of a single organ system."

Reminder: The 1995 examination is based on either the body areas or organ systems, not a combination of both.

Documentation Reminders and Frequently Asked Questions for 1995 Guidelines

• The measurement of at least three 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) or the patient’s general appearance must be documented in order to receive "credit" for "constitutional," under the 1995 "organ systems"
• "More detail" consists of at least two findings for at least two body areas or organ systems

1997 Guidelines
The content and documentation requirements for each type and level of examination are summarized below and described in detail in tables located on our website under the E/M Help Center. 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 such as "'e.g."  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.

There are two different types of 1997 examinations:

1. General Multi-System
2. Single Organ System

General Multi-System Examination
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
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 includes examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet (•), whether in a 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 a box with an unshaded border is expected.

Documentation Reminders and Frequently Asked Questions for 1995 and 1997 Guidelines

• 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
• Abnormal or unexpected findings of the examination of the unaffected or 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)

Resource: Evaluation and Management (E/M) Visits.