Evaluation and Management Services

Chest (Breasts)

System/Body Area: Gastrointestinal (Abdomen)

Elements of Examination: 

• Examination of abdomen with notation of presence of masses or tenderness 
• Examination of liver and spleen 
• Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Genitourinary (Abdomen) 

Lymphatic 

System/Body Area: Musculoskeletal

Elements of Examination:

• Examination of the back with notation of kyphosis or scoliosis 
• Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs 
• Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements.

System/Body Area: Extremities

Elements of Examination:Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler’s nodes)

System/Body Area: Skin

Elements of Examination:Inspection and/or palpation of skin and subcutaneous tissue (eg, stasis dermatitis, ulcers, scars, xanthomas) 

System/Body Area: Neurological/ Psychiatric

Elements of Examination:

Brief assessment of mental status including

• Orientation to time, place and person, 
• Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam : Problem Focused

Perform and Document:  One to five elements identified by a bullet.

Level of Exam : Expanded Problem Focused

Perform and Document:At least six elements identified by a bullet.

Level of Exam : Detailed

Perform and Document:At least two elements identified by a bullet from each of six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems

Level of Exam : Comprehensive

Perform and Document:Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems.

Cardiovascular Examination 

System/Body Area: Constitutional

Elements of Examination:

• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) 
• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)  

Head and Face

System/Body Area: Eyes 

Elements of Examination:Inspection of conjunctivae and lids (eg, xanthelasma) 

System/Body Area: Ears, Nose, Mouth and Throat

Elements of Examination:

• Inspection of teeth, gums and palate 
• Inspection of oral mucosa with notation of presence of pallor or cyanosis

System/Body Area: Neck

Elements of Examination:

• Examination of jugular veins (eg, distension; a, v or cannon a waves)
• Examination of thyroid (eg, enlargement, tenderness, mass) 

System/Body Area: Respiratory

Elements of Examination:

• Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 
• Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) 

System/Body Area: Cardiovascular

Elements of Examination:

• Palpation of heart (eg, location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4) 
• Auscultation of heart including sounds, abnormal sounds and murmurs 
• Measurement of blood pressure in two or more extremities when indicated (eg, aortic dissection, coarctation)

Examination of: 

• Carotid arteries (eg, waveform, pulse amplitude, bruits, apical-carotid delay) 
• Abdominal aorta (eg, size, bruits) 
• Femoral arteries (eg, pulse amplitude, bruits) 
• Pedal pulses (eg, pulse amplitude) 
• Extremities for peripheral edema and/or varicosities 

Evaluation and Management Services

System/Body Area :Cardiovascular 

Elements of Examination :

• Palpation of heart (eg, location, size, thrills) 
• Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of: 

• carotid arteries (eg, pulse amplitude, bruits) 
• abdominal aorta (eg, size, bruits) 
• femoral arteries (eg, pulse amplitude, bruits) 
• pedal pulses (eg, pulse amplitude) 
• extremities for edema and/or varicosities 

System/Body Area :Chest (Breasts)

Elements of Examination :

• Inspection of breasts (eg, symmetry, nipple discharge) 
• Palpation of breasts and axillae (eg, masses or lumps, tenderness) 

System/Body Area :Gastrointestinal (Abdomen)

Elements of Examination :

• Examination of abdomen with notation of presence of masses or tenderness 
• Examination of liver and spleen 
• Examination for presence or absence of hernia 
• Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses 
• Obtain stool sample for occult blood test when indicated 

System/Body Area :Genitourinary 

Elements of Examination :

MALE: 

• Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
•  Examination of the penis 
• Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness) 

FEMALE: 

Pelvic examination (with or without specimen collection for smears and cultures), including 

• Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 
• Examination of urethra (eg, masses, tenderness, scarring) 
• Examination of bladder (eg, fullness, masses, tenderness) Cervix (eg, general appearance, lesions, discharge) 
• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) 

CONTENT AND DOCUMENTATION REQUIREMENTS

System/Body Area : Constitutional 

Elements of Examination : Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) 

System/Body Area : Eyes

Elements of Examination : 

• Inspection of conjunctivae and lids 
• Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) 
• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages) 

System/Body Area : Ears, Nose, Mouth and Throat

Elements of Examination : 

• External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) 
• Otoscopic examination of external auditory canals and tympanic membranes 
• Assessment of hearing (eg, whispered voice, finger rub, tuning fork) 
• Inspection of nasal mucosa, septum and turbinates 
• Inspection of lips, teeth and gums 
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

System/Body Area : Neck

Elements of Examination : 

Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) 

System/Body Area : Respiratory

Elements of Examination : 

• Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 
• Percussion of chest (eg, dullness, flatness, hyperresonance)
• Palpation of chest (eg, tactile fremitus) 
• Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

CONTENT AND DOCUMENTATION REQUIREMENTS

System/Body Area :  Constitutional

Elements of Examination :  

• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) 
• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) 

System/Body Area :  Eyes

Elements of Examination :  

• Inspection of conjunctivae and lids 
• Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) 
• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

System/Body Area :Ears, Nose, Mouth and Throat 

Elements of Examination :  

• External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) 
• Otoscopic examination of external auditory canals and tympanic membranes 
• Assessment of hearing (eg, whispered voice, finger rub, tuning fork) 
• Inspection of nasal mucosa, septum and turbinates 
• Inspection of lips, teeth and gums 
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx 

System/Body Area :Neck

Elements of Examination :  

• Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)