Evaluation and Management

Physical Examination
Coding
Embrace the Gray Area That Can Lift Service Levels
Jen Godreau, BA, CPC, CPEDC
Content Director
Inhealthcare’s Supercoder
jenniferg@supercoder.com
www.supercoder.com
 Physical Examination
Embrace the GRAY!
1. Put your clinical savvy to the TEST
2. Make your doctor’s documentation work for
them

* Increase your vocabulary savvy

 4 Types of Examination
 Problem focused
 Expanded problem focused
 Detailed

 Comprehensive
Associated Terms and
Areas/Systems
 Problem Focused Exam
 Problem focused exams require 1 body area or 1-5
bulleted elements
 New patient visits, consults, ED services, and long-term care
requires that you meet the criteria of all 3 key components:

◦ 99201, 99245 or 99251 for PF(if you’re billing to a payer that

accepts consultation codes)
◦ 99281 for ED
◦ 99324 for Long-Term
 Problem Focused Exam
 Services that require performing and documenting 2 of
the 3 medically necessary key components listed with the
first levels of an established patient office visit are:
◦ a PF exam (99212)

◦ subsequent hospital care (99231)

◦ subsequent nursing facility ( 99307)

◦ long-term care (99334).

 Problem Focused Exam
 In a 99212, the physician is examining that body
area/system only.

Example:
a follow-up ear exam in which the OM is resolved
involves the physician examining the ear only.
Expanded Problem Focused Physical
Exam
 An expanded problem focused incorporates many body
areas or systems

◦ a limited examination of the affected body area or system plus 1-6

systematic or related systems

 Only give credit for performed and documented

medical physician examination findings that were
done based on the encounter’s medical necessity
 Example:
 Our patient with OM on initial presentation has a
fever, runny nose, and stomach ache. The physician
examines those systems and documents his findings.
 In addition to examining the ear (1 body system),
you have stomach under body system “GI. Although
the physician also examined the patient’s nose, you
still have 2 systems.
◦ Ear, nose, mouth, and throat all qualify as 1 system.

 If the patient also had goop coming out of R eye, the

eye exam counts as an additional system.
 The 1 Count Rule
 Expanding our ENMT (remember the mouth in there,
for instance white patches on tongue and prickly red
rash all over tummy, the tongue would count under
ENMT. The rash would count under skin.) 1 system
credit no matter the structures involved.
Test it
 Wt 186 lbs
 Ht 66 in
 BP: 120/80 How many
PR: unfound


 Temp: 99.0
systems?
 POx: 99%
 Dress in disarray.

The answer is 1! Even though you have 7 pieces of

constitutional information – you get credit for a system
once only.
Test It
 You have murmur documentation that indicates a
cardiovascular (CV) exam and the abbreviation “c/c/e.”
Is this notation, plus CV, enough body areas/systems for
an expanded problem-focused exam?
Yes, c/c/e stands for cyanosis, clubbing, edema
◦ Physicians may use the medical abbreviation “no c/c/e,” for instance, to
indicate adequate blood oxygenation in physical examination of the
extremities.
Therefore, you have two body areas/systems examined
(cardiovascular, extremity), which equates to an
expanded problem-focused exam.
 Expanded Problem Focused Physical
Exam
 On 3/3 services, expanded PF is required for both new
patient office visit codes 99202 and 99203, consult
codes 99242 and 99252, ED codes 99282 and 99283,
and on long-term care code 99325.

 On 2/3 services, EPF is listed as a component of 99213,

99232, 99308 for NF, and 99385 for LTC.
Detailed exam
The 1995 E/M Documentation Guidelines distinguish
between an expanded problem focused examination and a
detailed exam as both requiring at least two body areas
and/or systems and that one is a ‘limited exam’ and the
other is ‘extended’.
Tip: For areas that your physician regularly examines,
be familiar with his usual detail. That way, when you see
more detail, you can distinguish an expanded problem
focused exam from a detailed one.
 Keywords
 For respiration: Documentation will have the respiratory rate,
assessment of respiratory effort, auscultation findings and usually
a re-evaluation of the respiratory system and usually a
reevaluation of the respiratory system.
 For abdomen examination: Documentation would have how the
abdomen looks in general, palpation of liver, spleen, masses, area
of pain, degree of pain, bowel sounds, etc.

 Hint: If you’re taking the E/M or primary care specialty exams

that the American Academy of Professional Coders (AAPC) offers
make sure you know the difference between limited and detailed
documentation. Pay attention to exam findings that are longer and
more detailed than typical area or system findings. These are
probably detailed physical examinations.
Detailed exam
 A detailed exam goes to 3/3 key components for a 99203,
99243, 99253, 99284, the lowest level of observation
care (99218 and 99234) and NF care (99304), as well
as midlevel long-term care 99326.
 In the 2/3 category, detailed exam is listed in 99214,

99233, 99309, 99336.

 Using the 1997 guidelines, you have to have 12-17
bulleted elements from 2 or more systems for a
detailed exam.
 Compare 99213 to 99214
 1995 guidelines require 99213 has a expanded problem
focused exam of 2-6 brief systems.
◦ For instance, documentation includes:
General: alert and responsive
Ears: left clear, right fluid
Nose: clear drainage
Chest: clear
CV: No murmur
This counts as 4 systems examined for 99213
 Compare 99213 to 99214
Here is a 99214:
General: Crying on Mom’s lap with flaring nostrils
ENT: clear runny nose, ears clear
Resp: Resp. rate 30 , substernal retractions, in obvious distress.
Rales and rhonchi bilaterally. Will do neb and reevaluate.
Heart: Heart Rate rapid but normal
Re-eval: Improved but still having wheezing. Resp rate 20 will repeat neb
Re-eval: Much improved, no further wheezing. Resp rate normal.
 

In this example, you have 1 system in detail – respiration,

plus you have 3 systems that are brief: Constitutional,
ENT, and Cardiovascular.
 Comprehensive Physical Exam
 Requires a general multi-system exam of 8 or more
systems or complete exam of a single organ system.

For the complete exam requirements, see the 1997 EM

guidelines individual single system exam requirements
at:
http://www.supercoder.com/category/cms/evaluation-ma
nagement/
 Comprehensive Physical Exam
In comprehensive, you count body systems only – all
eight checkboxes in the data quantity area must be
systems, not body areas.

The 1997 guidelines require 18 or more bulleted

elements from 9 or more systems for a general multi-
system exam.
Other Exams
With the 1995 EM guidelines (the 1997 general multi-system exam guidelines
are indicated in italics), you can have:
Type of Physical Examination Body System/Area(s) required
Problem focused 1 system or area
(1-5 bulleted elements)
Expanded problem focused 2-7 brief systems or areas
(6-11 bulleted elements)
Detailed 1 system or area in greater detail and 1-6 additional BRIEF
system(s) (notice you only need 1 additional limited system here;
so you could have a detailed eye exam in which you’d have
documentation describing the cornea, pupil, reactivity to light,
eyelids, lashes, etc. and 1 other system like vitals for general
constitution – and you’d have a detailed exam; same with
abdomen for abdominal pain describing left quadrant pain at 7 no
masses, soft to palpation, etc. with skin palid for skin and you’d
have a detailed exam)
(12-17 bulleted elements in 2 organ systems)
Comprehensive 8+ systems OR complete single system exam
(18 or more bulleted elements from 9 or more systems
Complete single system, see individual single system exam
requirements.)
 1995 or 1997?
Tip: If your practice or group uses the `95 guidelines, still keep a copy
of the `97 ones. These can help guide you in areas to count certain
terms.
Example: Going back to the previous murmur and c/c/e example,
suppose the doctor documented “edema” and “c/c/e”, but not the murmur.
You could count edema for the CV, and clubbing and cyanosis could go to
musculoskeletal.
The 1997 guidelines show the following bullet under Musculoskeletal:
• Inspection and/or palpation of digits and nails (e.g.,clubbing,
cyanosis, inflammatory conditions, petechiae,ischemia, infection, nodes)
The 1997 guidelines show the following bullet under Cardiovascular:
• Examination of extremities of edema and/or varicosities
1995 1997
 Improve Your Vocab
AAO: Awake, Alert and Oriented NAD: no abnormalities detected
AAPC: EM certification audit sheet PERRL: Pupils equal, round &
from Stephanie Jones's E-M for reactive to light & accommodation
Coding Class Part (Stephanie Jones, ROM: Range of Motion
CPC, CEMC)
RRR: Regular Rate and Rhythm/
c/c/e: Cyanosis, Clubbing, Edema Respiration, Rate, and Rhythm
CTA: Clear To Auscultation WDWN: Well Developed Well
DTR: Deep tendon reflex Nourished
WNL: Within Normal Limits
Edema: Edema is swelling caused
by excess fluid trapped in your
body's tissues. Although edema can
affect any part of your body, it's most
commonly noticed in your hands,
arms, feet, ankles and legs.
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