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Physical
Exam
The
physical exam is one of the three
key components of E/M documentation.
Similar
to the levels of history, there
are four levels of physical exam documentation:
-
Problem
Focused
-
Expanded
Problem Focused
-
Detailed
-
Comprehensive
Coding
Tip:
The 1997 E/M guidelines are quite rigid and force physicians to document
the exam using specific bullets. The 1997 physical exam rules are much
more “black and white”—either the bullets are there or they
aren’t.
1997
Physical Exam Rules
General Multi-System Exam
For the purposes of documenting the physical exam, the 1997 E/M guidelines
rely on the use of bullets
from well defined organ
systems:
1997
Problem Focused Exam
One to five bullets
from one or more organ systems. So having
only the Vitals as one bullet point counts as a Problem Focused Exam.
Example
Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: CTA
CV: RRR, no MRGs
(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
Total bullets = four (although only one to five bullets are required)
1997
Expanded Problem Focused Exam
At least six
bullets from any organ
systems
Example
Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, nontender
Extremities: No peripheral edema
(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for examination of the abdomen)
(1 bullet for examination of extremities for edema)
Total bullets = six
1997
Detailed Exam
At least two bullets
from six organ systems
OR 12 bullets from
two or more organ systems
Example
Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time
(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)
Total bullets = 12
1997
Comprehensive Exam
Two bullets
from EACH of nine
organ
systems
Example
Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA
HENT: Atraumatic; oropharynx clear with moist mucous membranes and no
mucosal ulcerations;
normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or
subcutaneous nodules
Psych: Appropriate affect, alert and oriented to person, place and time
Systems and Bullets
Constitutional
(1 bullet for three vital signs)
(1 bullet for general appearance)
Eyes
(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)
Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose—“atraumautic”)
(1 bullet for examination of oropharynx)
Neck
(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)
Respiratory
(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)
Cardiovascular
(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)
Gastrointestinal
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
Lymphatic
(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)
Skin
(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)
Psychiatric
(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)
Total systems = 10 (although only nine are required)
Total bullets = 20 (although only 18 are required—two in EACH of
nine systems)
Coding
Tip:
Although it may seem tedious at first, it is recommended that physicians
use the 1997 bullet points when quantifying the physical exam. The best
approach is to review the organ systems and bullets and construct a
pre-set template for each level of exam. This will ensure optimal
compliance with the somewhat arbitrary rules for documenting the exam.
Organ
Systems
The 1997 E/M guidelines recognize the following organ systems:
1. Constitutional
2. Eyes
3. Ears, nose, mouth and throat
4. Neck
5. Respiratory
6. Cardiovascular
7. Chest (breasts)
8. Gastrointestinal (abdomen)
9. Genitourinary (male)
10.Genitourinary (female)
11. Lymphatic
12. Musculoskeletal
13. Skin
14. Neurologic
15. Psychiatric
Physical
Exam Bullets
Constitutional
1) Three vital signs
2) General appearance
Eyes
1) Inspection of conjunctivae and
lids
2) Examination of pupils and
irises (PERRLA)
3) Ophthalmoscopic discs and
posterior segments
Ears, Nose, Mouth, and Throat
1) External appearance of the
ears and nose (overall appearance, scars, lesions, masses)
2) Otoscopic examination of the
external auditory canals and tympanic membranes
3) Assessment of hearing
4) Inspection of nasal mucosa,
septum and turbinates
5) Inspection of lips, teeth and
gums
6) Examination of oropharynx:
oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and
posterior pharynx
Neck
1) Examination of neck (e.g.,
masses, overall appearance, symmetry, tracheal position, crepitus)
2) Examination of thyroid
Respiratory
1) Assessment of respiratory
effort (e.g., intercostal retractions, use of accessory muscles,
diaphragmatic movement)
2) Percussion of chest (e.g.,
dullness, flatness, hyperresonance)
3) Palpation of chest (e.g.,
tactile fremitus)
4) Auscultation of the lungs
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)
Chest (Breasts)
1) Inspection of the breasts
(e.g., symmetry, nipple discharge)
2) Palpation of the breasts and
axillae (e.g., masses, lumps, tenderness)
Gastrointestinal (Abdomen)
1) Examination of the abdomen
with notation of presence of masses or tenderness
2) Examination of the liver and
spleen
3) Examination for the presence
or absence of hernias
4) Examination (when indicated)
of anus, perineum, and rectum, including sphincter tone, presence of
hemorrhoids,
rectal masses
5) Obtain stool for occult blood
testing when indicated
Genitourinary (Male)
1) Examination of the scrotal
contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular
mass)
2) Examination of the penis
3) Digital rectal examination of
the prostate gland (e.g., size, symmetry, nodularity, tenderness)
Genitourinary (Female)
Pelvic examination (with or without specimen collection for smears and
cultures, which may include:
1) Examination of the external
genitalia (e.g., general appearance, hair distribution, lesions)
2) Examination of the urethra
(e.g., masses, tenderness, scarring)
3) Examination of the bladder
(e.g., fullness, masses, tenderness)
4) Examination of the cervix
(e.g., general appearance, discharge, lesions)
5) Examination of the uterus
(e.g., size, contour, position, mobility, tenderness, consistency, descent
or support)
6) Examination of the adnexa/parametria
(e.g., masses, tenderness, organomegaly, nodularity)
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)
Psychiatric
1) Description of patient’s
judgment and insight
Brief assessment of mental status which may include
1) orientation to time, place, and
person
2) recent and remote memory
3) mood and affect
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