1997 Physical Exam Rules

General Multi-System Exam (for specialty exams, click here.)

Organ Systems

The 1997 E/M guidelines recognize the following organ systems:

99211-- 1�5 bullets (1 or more body areas or system)

99212-- 6 bullets (1 or more body areas or system)
99213-- 12 bullets in 2 or more body areas/systems
99214-- 2 bullets in 9 or more body area or systems: or comlete single organ
system

6. Cardiovascular
11. Lymphatic
12. Musculoskeletal
13. Skin
14. Neurologic
15. Psychiatric

Physical Exam Bullets

Constitutional

1) Three vital signs

2) General appearance

Cardiovascular

1) Palpation of the heart (location, size, thrills)

2) Auscultation of the heart with notation of abnormal sounds and murmurs
3) Assessment of lower extremities for edema and/or varicosities
4) Examination of the carotid arteries (e.g., pulse amplitude, bruits)
5) Examination of abdominal aorta (e.g., size, bruits)
6) Examination of the femoral arteries (e.g., pulse amplitude, bruits)
7) Examination of the pedal pulses (e.g., pulse amplitude)

Lymphatic

Palpation of lymph nodes two or more areas:

1) Neck
2) Axillae
3) Groin
4) Other

Musculoskeletal

1) Examination of gait and station

2) Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis,
inflammatory conditions, petechiae, ischemia, infections, nodes)

Examination of the joints, bones, and muscles of one or more of the following six
areas:
 a) head and neck
b) spine, ribs, and pelvis
c) right upper extremity
d) left upper extremity
e) right lower extremity
f) left lower extremity

The examination of a given area may include:

1) Inspection and/or palpation with notation of presence of any misalignment,

asymmetry, crepitation,
2) defects, tenderness, masses or effusions
3) Assessment of range of motion with notation of any pain, crepitation or
contracture
4) Assessment of stability with notation of any dislocation, subluxation, or
laxity
5) Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with
notation of any atrophy or abnormal movements

Skin

1) Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)

2) Palpation of the skin and subcutaneous tissue (e.g., induration,

subcutaneous nodules, tightening)

Neurologic

1) Test cranial nerves with notation of any deficits

2) Examination of DTRs with notation of any pathologic reflexes (e.g.,
Babinksi)
3) Examination of sensation (e.g., by touch, pin, vibration, proprioception)

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E/M University Coding Tip: the 1995 physical exam rules may seem appealing, but
they are too vague and subjective to be relied upon to withstand a systematic
audit. It is recommended that physicians utilize the more concrete 1997 physical
exam rules (see above)

1997 Specialty Exams

1995 Physical Exam Rules

For the purposes of documenting the physical exam, the 1995 E/M guidelines
recognize the following body areas and organ systems:

Body Areas

1) Head, including the face

2) Neck
3) Chest, including breasts and axillae
4) Abdomen
5) Genitalia, groin, buttocks
6) Back, including spine
7) Each extremity
Organ Systems

1) Constitutional (e.g., vital signs, general appearance)

2) Eyes
3) Ears, nose, mouth and throat
4) Cardiovascular
5) Respiratory
6) Gastrointestinal
7) Genitourinary
8) Musculoskeletal
9) Skin
10) Neurologic
11) Psychiatric
12) Hematologic/lymphatic/immunologic

Using the 1995 E/M guidelines, the various levels of physical exam are defined as
follows:

Problem Focused�a limited examination of the affected body are or organ system

Expanded Problem Focused�a limited examination of the affected body area or organ
system and other symptomatic or related organ systems

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

Musculoskeletal Examination of gait and station

Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis,
inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles 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:
Inspection and/or palpation with notation of presence of any misalignment,
asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of any pain, crepitation or
contracture
Assessment of stability with notation of any dislocation (luxation),
subluxation or laxity
Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements

Skin Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous
nodules, tightening)

Neurologic Test cranial nerves with notation of any deficits

Examination of deep tendon reflexes with notation of pathological reflexes (eg,
Babinski)
Examination of sensation (eg, by touch, pin, vibration, proprioception)

Psychiatric Description of patient�s judgment and insight

Brief assessment of mental status including:
orientation to time, place and person
recent and remote memory
mood and affect (eg, depression, anxiety, agitation)