1995 Guidelines for Physical Exam

7 Body Areas 

 Head-including face including face 

 Neck 

 Chest-including breast and axillae 

 Abdomen Back including spine

 Back including spine 

 Genitalia, groin, buttocks 

 Each extremity

 Problem Focused-1 Body System including affected area including affected area (99281) (99281) 

 Expanded Problem Focused - a limited a limited examination of the affected body area or organ system and related body area(s) or 41 organ system and related related body area(s) area(s) or organ system(s) 

 2-4 Body systems including affected 4 Body systems including affected area (99282/99283) (99282/99283)

 Detailed - an extended examination of an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or  system(s) and any other symptomatic symptomatic or related body area(s) or organ system(s) 

 5-7 Body areas or systems 7 Body areas or systems including affected area including affected area (99284) (99284) 

 Comprehensive - a general multi-system

 Comprehensive a general multi system examination 

 8 or more 8 or more organ systems including affected area affected area (99285) (99285)

Documentation Guidelines  Physical Exam-Record Format

 Checklists to indicate performance of any item ok 

□ Lungs CTAB 

 Brief statement or notation “negative” or “normal” ok for normal findings “normal” ok for normal findings ENT-normal Specific abnormal and clinically relevant 

 Specific Specific abnormal abnormal and clinically clinically relevant relevant negative must be documented negative must be documented- “abnormal” “abnormal” without elaboration insufficient Abdomen soft, tender RLQ, BS poor