General multi system examination and single organ system examination

Examination

As stated previously, there are two versions of the documentation guidelines – the 1995 version and the 1997 version. The most substantial differences between the two versions occur in the examination documentation section. Either version of the documentation guidelines, not a combination of the two, may be used by the provider for a patient encounter.


The levels of E/M services are based on four types of examination:

** Problem Focused – A limited examination of the affected body area or organ system;

** Expanded Problem Focused – A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s);

** Detailed – An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s); and

** Comprehensive – A general multi-system examination or complete examination of a single organ system (and other symptomatic or related body area(s) or organ system(s) – 1997 documentation guidelines).

An examination may involve several organ systems or a single organ system. The type and extent of the examination performed is based upon clinical judgment, the patient’s history, and nature of the presenting problem(s).

The 1997 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit: general multi-system examination and single organ examination.

A general multi-system examination involves the examination of one or more organ systems or body areas, as depicted in the chart below.


TYPE OF EXAMINATION       DESCRIPTION

Problem Focused                           Include performance and documentation of one to five  elements identified by a bullet, whether in a box with a  shaded or unshaded border.

Expanded Problem Focused            Include performance and documentation of at least six elements identified by a bullet, whether in  a box with a shaded or unshaded border.

Detailed                  Include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet is expected. Alternatively, may include performance and documentation of at least twelve elements identified by a bullet in two or more organ systems or body areas.

Comprehensive            Include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by bullet is expected.*

* The 1995 documentation guidelines state that the medical record for a general multi-system examination should include findings about eight or more organ systems.


A single organ system examination involves a more extensive examination of a specific organ system, as depicted in the chart below.


TYPE OF EXAMINATION DESCRIPTION


Problem Focused Include performance and documentation of one to five elements identified by a bullet, whether in a box with a shaded or unshaded border.


Expanded Problem Focused Include performance and documentation of at least six elements identified by a bullet, whether in a box with a shaded or unshaded border.

Detailed Examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet, whether in a box with a shaded or unshaded border. Eye and psychiatric examinations include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or unshaded border.

Comprehensive Include performance of all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a
shaded border and at least one element in a box with an unshaded border is expected.




Both types of examinations may be performed by any physician, regardless of specialty.

Some important points that should be kept in mind when documenting general multi-system and single organ system examinations (in both the 1995 and the 1997 documentation guidelines) are:

** Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented.

A notation of “abnormal” without elaboration is not sufficient.

** Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

** A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).