Pelvic examination (with or without specimen collection for smears and cultures), including:
Palpation of lymph nodes in two or more areas:
Examination of joint(s), bone(s) and muscle(s) of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:
Brief assessment of mental status, including:
To qualify for a given level, your exam must meet the following content and documentation requirements (these are summarized in the table "Exam content and documentation requirements"):
One way to remember the distinctions is to “think in sixes”: The lowest level of exam has fewer than six bulleted elements, the next level has six or more, the next has 12 or more, and the highest has 18 or more. Also note that the definition of the detailed exam is not as complicated as it may sound. The first alternative (at least two elements from each of six systems or body areas) is just a special case of the second. If you document 12 bulleted elements, you've documented a detailed exam, whether those 12 elements are spread evenly over 6 systems and body areas or not. The points to remember for the detailed exam are 12 bulleted elements and at least two systems or body areas. If you prefer to think in terms of six systems and two bulleted points per system, fine. Just remember that this is only one possibility.
Note the peculiar wording of the requirement for the comprehensive general multisystem exam: While the guidelines say explicitly that you must perform all the elements of the exam identified by bullets in the nine or more systems or body areas you examine, they require that you document only two per system or area. This distinction is evidently deliberate. The rationale, as best we can understand, is that requiring all bulleted items to be covered in the exam ensures that the physician work going into the exam is adequate to justify the level of reimbursement, while requiring documentation of only two elements somewhat relieves the physician's documentation task.
| Exam type | Requirements | Systems/Areas | Bulleted elements |
|---|---|---|---|
| Problem focused | Perform and document one to five elements identified by a bullet. | 1+ | |
| Expanded problem focused | Perform and document at least six elements identified by a bullet. | 1+ | 6+ |
| Detailed | Perform and document at least 12 elements identified by a bullet in two or more systems/areas. | 2+ | 12+ |
| Comprehensive (general multisystem) | Perform all elements identified by a bullet and document at least two elements identified by a bullet from each of at least nine systems/areas.* | 9+ | 18+ |
The requirements for the problem focused exam are minimal. If you or your ancillary staff measure and document even three of the seven vital signs listed in the chart, you have documented a problem focused exam. For instance, a notation of “BP 126/86, P 82, WT 190” meets the requirements of the first bullet under the Constitutional system, and since you performed and documented “one to five elements identified by a bullet in one or more organ system(s) or body area(s),” you've met the requirements for documenting a problem focused exam.
For an expanded problem focused exam, the threshold is six elements identified by a bullet in one or more organ system(s) or body area(s). Consider this example: You see a 55-year-old man who has returned for follow-up of his hypertension. His only complaint is a scratchy throat that he's had for the past several days. Your observations are noted as follows:
The following elements identified by bullets in the CMS table are documented in the note:
To be precise, you have documented that you examined at least 11 elements identified by a bullet. That's more than enough to substantiate that you did an expanded problem focused exam and almost enough for a detailed exam. In fact, if you had happened to add a comment about the patient's general appearance (a bulleted item under the Constitutional system), you'd have documented 12 items in two or more systems, which is the minimum required for a detailed exam.
Finally, there is the comprehensive multisystem exam. Previously, the guidelines required that such an exam include findings from eight or more of the 12 organ systems. The revised guidelines require documentation of at least two elements from each of nine body areas and/or systems out of the 14 body areas or systems recognized. This is more stringent in that it raises the bar from eight to nine and requires documenting two exam elements for each system or area examined, but it is less stringent at least in that you can now count organ systems and body areas.
In the example discussed above, the physician performed and documented at least two elements from each of the following five body areas or organ systems: Constitutional (assuming the addition of a note about general appearance); Ears, Nose, Mouth and Throat; Neck; Respiratory; and Cardiovascular. A comprehensive multisystem exam would pretty clearly be inappropriate given the clinical situation and chief complaint, but just by way of illustration, it would also require the physician to document at least two elements from four of the following additional body areas or organ systems to bring the total number of body areas or organ systems to nine: Eyes; Chest (Breasts); Gastrointestinal (Abdomen); Genitourinary; Lymphatic; Musculoskeletal; Skin; Neurologic; and Psychiatric. As noted above, the guidelines require that all the elements listed be performed for each body area or organ system examined, even though only two in each area or system must be documented.