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)

History Issues

 ROS and PFSH may be recorded by others 

 The provider must reference the elements 

 ROS not as easy to obtain from NNs 

 No need to record things in more than one place 

 ROS elements may be documented in the HPI 

 A chief complaint will generally include at least one ROS 

 Chest pain associated with nausea and vomiting 

 HPI element for associated signs/sxs 

 GI ROS element 

 Same statement may not satisfy multiple sub Same statement may not satisfy multiple sub-elements of elements of HPI or ROS 

 Chest pain since this morning can not be both timing and duration