Eye Examination

Elements of Examination :

• Test visual acuity (Does not include determination of refractive error) 
• Gross visual field testing by confrontation 
• Test ocular motility including primary gaze alignment 
• Inspection of bulbar and palpebral conjunctivae 
• Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes 
• Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology 
• Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film 
• Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus
•  Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) 

Ophthalmoscopic examination through dilated pupils (unless contraindicated) of Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages)

Genitourinary 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) 

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) 

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) 

System/Body Area:Cardiovascular

Elements of Examination : 

Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (e.g. pulses, temperature, edema, tenderness) 

System/Body Area:Chest (Breasts)

System/Body Area:Gastrointestinal (Abdomen)

 

Elements of Examination : 

Examination of abdomen with notation of presence of masses or tenderness 

Examination for presence or absence of hernia 

Examination of liver and spleen 

Obtain stool sample for occult blood when indicated 

System/Body Area:Genitourinary

 

Elements of Examination : 

MALE: Inspection of anus and perineum 

• Examination (with or without specimen collection for smears and cultures) of genitalia including: 
• Scrotum (eg, lesions, cysts, rashes) Epididymides (eg, size, symmetry, masses) 
• Testes (eg, size, symmetry, masses)
• Urethral meatus (eg, size, location, lesions, discharge) 
• Penis (eg, lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities) 

Digital rectal examination including: 

• Prostate gland (eg, size, symmetry, nodularity, tenderness)
• Seminal vesicles (eg, symmetry, tenderness, masses, enlargement) 
• Sphincter tone, presence of hemorrhoids, rectal masses 

System/Body Area:Genitourinary

 

Elements of Examination : 

FEMALE:

Includes at least seven of the following eleven elements identified by bullets:

•  Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple discharge) 
•  Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses  

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

• External genitalia (eg, general appearance, hair distribution, lesions) 
• Urethral meatus (eg, size, location, lesions, prolapse) 
• Urethra (eg, masses, tenderness, scarring) 
• Bladder (eg, fullness, masses, tenderness) 
• Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 
• Cervix (eg, general appearance, lesions, discharge) 
• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) 
• Anus and perineum

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)

WHAT IS DOCUMENTATION

 WHY IS IT IMPORTANT?

Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

• the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time. 
• communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care; 
• accurate and timely claims review and payment; 
• appropriate utilization review and quality of care evaluations; and 
• collection of data that may be useful for research and education.  

An appropriately documented medical record can reduce many of the hassles associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

WHAT DO PAYERS WANT AND WHY?  

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

• the site of service; 
• the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or 
• that services provided have been accurately reported.  

RISK OF SIGNIFICANT COMPLICATIONS

Level of Risk - Minimal

Presenting Problem(s) -  One self-limited or minor problem, eg, cold, insect bite, tinea corporis

Diagnostic Procedure(s) Ordered -  Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, eg, echocardiography KOH prep 

Management Options Selected  - Rest Gargles Elastic bandages Superficial dressings 

Level of Risk - Low

Presenting Problem(s) -  Two or more self-limited or minor problems One stable chronic illness, eg, well controlled hypertension, non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain

Diagnostic Procedure(s) Ordered -  Physiologic tests not under stress, eg, pulmonary function tests Non-cardiovascular imaging studies with contrast, eg, barium enema Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies 

Management Options Selected  - Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives

Level of Risk - Moderate

Presenting Problem(s) -  One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness

Diagnostic Procedure(s) Ordered -  Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram, cardiac catheterization Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis

Management Options Selected  - Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation 

Level of Risk - High

Presenting Problem(s) -  One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory loss

Diagnostic Procedure(s) Ordered -  Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic Endoscopies with identified risk factors Discography

Management Options Selected  - Elective major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis 

RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.

DG: Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented. 

DG: If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure eg, laparoscopy, should be documented. 

DG: If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented. 

DG: The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied. 

The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. 

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.

Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed. 

DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, should be documented. 

DG: The review of lab, radiology and/or other diagnostic tests should be documented. An entry in a progress note such as "WBC elevated" or "chest xray unremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results. 

DG: A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. 

DG: Relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of "Old records reviewed” or "additional history obtained from family” without elaboration is insufficient. 

DG: The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented. 

DG: The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented.  

DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING

The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

• the number of possible diagnoses and/or the number of management options that must be considered; 
• the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and 
• the risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.  

NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS 

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems. 

DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. 

• For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected. 
• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnoses or as "possible,” "probable,” or "rule out” (R/O) diagnoses. 

DG: The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications. 

DG: If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.  

DOCUMENTATION OF EXAMINATION

The levels of E/M services are based on four types of examination that are defined as follows:

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 other symptomatic or related organ system(s). 

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

Comprehensive -- a general multi-system examination or complete examination of a single organ system.  

For purposes of examination, the following body areas are recognized: 

• Head, including the face 
• Neck 
• Chest, including breasts and axillae 
• Abdomen
• Genitalia, groin, buttocks 
• Back, including spine 
• Each extremity 

For purposes of examination, the following organ systems are recognized: 

• Constitutional (e.g., vital signs, general appearance) 
• Eyes 
• Ears, nose, mouth, and throat 
• Cardiovascular 
• Respiratory 
• Gastrointestinal 
• Genitourinary 
• Musculoskeletal 
• Skin 
• Neurologic 
• Psychiatric 
• Hematologic/lymphatic/immunologic 

The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

DG: 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 insufficient. 

DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. 

DG: 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). 

DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.  

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

• past history (the patient's past experiences with illnesses, operations, injuries and treatments); 
• family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and 
• social history (an age appropriate review of past and current activities).  

For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI. 

DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH.  

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services. 

DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; subsequent nursing facility care; domiciliary care, established patient; and home care, established patient. 

DG: At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and homecare, new patient. 

REVIEW OF SYSTEMS (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized: 

• Constitutional symptoms (e.g., fever, weight loss) 
• Eyes 
• Ears, Nose, Mouth, Throat 
• Cardiovascular 
• Respiratory 
• Gastrointestinal 
• Genitourinary 
• Musculoskeletal 
• Integumentary (skin and/or breast) 
• Neurological 
• Psychiatric 
• Endocrine 
• Hematologic/Lymphatic 
• Allergic/Immunologic  

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI. 

DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented. 

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. 

DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

 DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented. 

HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

• location; 
• quality; 
• severity;
• duration; 
• timing; 
• context; 
• modifying factors; 
• and associated signs and symptoms.  

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI. 

DG: The medical record should describe one to three elements of the present illness (HPI). 

An extended HPI consists of four or more elements of the HPI. 

DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.