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

Embrace the GRAY!
1. 2.

Put your clinical savvy to the TEST Make your doctor¶s documentation work for
them * Increase your vocabulary savvy

` Problem

focused problem focused

` Expanded

` Detailed ` Comprehensive

Associated Terms and Areas/Systems


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



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).


In a 99212, the physician is examining that body area/system only.

a follow-up ear exam in which the OM is resolved involves the physician examining the ear only.


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


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 ³GI. Although the physician also examined the patient¶s nose, you still have 2 systems.
Ear, nose, mouth, and throat all qualify as 1 system.



the patient also had goop coming out of R eye, the eye exam counts as an additional system.

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. 


Wt 186 lbs Ht 66 in BP: 120/80 PR: unfound Temp: 99.0 POx: 99% Dress in disarray.

How many systems?

The answer is 1! Even though you have 7 pieces of
constitutional information ± you get credit for a system once only.


You have murmur documentation that indicates a cardiovascular (CV) exam and the abbreviation ³c/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 ³no 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.


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.



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 µlimited exam¶ and the other is µextended¶.

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.



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. 



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.



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

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.


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/evaluationmanagement/

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 multisystem exam.

With the 1995 EM guidelines (the 1997 general multi-system exam guidelines are indicated in italics), you can have:
Type of Physical Examination
Problem focused Expanded problem focused Detailed

Body System/Area(s) required
1 system or area (1-5 bulleted elements) 2-7 brief systems or areas (6-11 bulleted elements) 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) 8+ systems R complete single system exam (18 or more bulleted elements from 9 or more systems omplete single system, see individual single system exam requirements.)



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 ³edema´ and ³c/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



` `

AAO: Awake, Alert and Oriented

AAPC: EM certification audit sheet from Stephanie Jones's E-M for Coding Class Part (Stephanie Jones, CPC, CEMC)
` ` `

EOMI: Extraocular Movements Intact
` ` `

NAD: no abnormalities detected

PERRL: Pupils equal, round & reactive to light & accommodation
` `

c/c/e: Cyanosis, Clubbing, Edema
CTA: Clear To Auscultation DTR: Deep tendon reflex

ROM: Range of Motion

RRR: Regular Rate and Rhythm/ Respiration, Rate, and Rhythm

Edema: Edema is swelling caused ` WDWN: Well Developed Well by excess fluid trapped in your body's Nourished tissues. Although edema can affect any ` WNL: Within Normal Limits part of your body, it's most commonly noticed in your hands, arms, feet, ankles and legs.

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