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Evaluation & Management Coding - The Basics - Part 3

By Lisa Hernandez
April 18, 2012

In this edition of Evaluation & Management Coding – The Basics, we will be discussing the exam component in more detail.  As previously mentioned, it is very important to look to your Medicare Administrator for guidance on their “rules” for E/M coding.  Most carriers have sections on their site dedicated to E/M questions, answers, examples, etc.

The exam is the provider’s assessment of the patient, sometimes referred to as the “hands-on” portion of the visit or the “objective” part of a SOAP note.  (Please refer to the Audit Tool linked in this article.)

The following are the body areas and organ systems that are recognized:

Body Areas

Organ Systems

Head, including face




Chest, breast, and axillae

Ears, nose, mouth, and throat



Genitalia, groin, and buttocks


Back, including spine


Each extremity






Hemic, lymphatic, and immunologic


Now what? Luckily, CMS has a couple of great tools for you to become familiar with using – the 1995 & 1997 Documentation Guidelines:

Both of these guides are important for all of the key elements – history, exam, and medical decision making, but they can be used particularly for help with the exam portion. Once you have read through both of them, it will become apparent why.

The Exam portion of the 1995 Guidelines is very general. It gives the above referenced body areas and organ systems and instructions regarding the different levels of the exam:

  • Problem Focused – A limited exam of one affected body area or organ system
  • Expanded Problem Focused  (EPF) – 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 (the guidelines state that you need 8 out of the 12 Organ Systems documented to receive a comprehensive level of exam)

Well… do you decide what is an expanded problem focused exam and what is a detailed exam? Check with your Medicare carrier to see if they have any published rules. Some auditors use 2–4 body areas and organ systems for an EPF exam and 5–7 body areas and organ systems for a detailed exam, while others go by the amount of documentation that is addressed under each body area and/or organ system. If your Medicare carrier doesn’t have any published rules or literature they can provide, you will need to decide what is and isn’t considered appropriate for a detailed exam based on all the information that is available.

Since the 1995 Guidelines can be described as a little vague, CMS decided to put out some additional information in the form of the 1997 Documentation Guidelines. There is a noticeable difference in the size of each – the 1997 Guidelines contain much more information.

Again, just looking at the exam portion of the 1997 guidelines will show that they contain several different organ system examinations with “bullets” and shaded and unshaded boxes.  The following are the different types of exams in the 1997 Guidelines:

General Multi-System Examination

Musculoskeletal Examination

Cardiovascular Examination

Neurological Examination

Ear, Nose, and Throat Examination

Psychiatric Examination

Eye Examination

Respiratory Examination

Genitourinary Examination

Skin Examination

Hematologic/Lymphatic/Immunologic Examination



Each examination has a certain amount of “bullets” that must be documented in the shaded or unshaded boxes in order to qualify for a certain level of service.  There are some minor differences between the exams, but most follow the criteria listed below:

  • Problem Focused – 1 – 5 bullets in a shaded or unshaded box
  • Expanded Problem Focused (EPF) – At least 6 elements in a shaded or unshaded box
  • Detailed – At least 12 bullets in a shaded or unshaded box (Eye and Psychiatric Examinations need 9 bullets)
  • Comprehensive – All elements with a bullet should be performed and documentation should include every bullet in a shaded box and at least 1 bullet in each unshaded box

This becomes easier the more you work with the guidelines and use them on a regular basis.

CMS allows the provider to use either the 1995 or 1997 Guidelines for a visit – the provider is not allowed to mix the two together for a single encounter, but can use them for different visits throughout the day.  It’s important to audit with both guidelines until you get a feel for them and know which one typically gives your provider the highest level of service for the entire visit.  There are plenty of charts that only get an EPF exam with the 1997 Guidelines but a detailed exam with the 1995 Guidelines.  Use the one that is most beneficial to your provider(s).

NOTE: If you are on an Electronic Medical Record (EMR) it is usually easier to use the 1997 Guidelines because the bullets translate to discrete data (aka checkboxes) better than a note that has been free-texted or dictated into the EMR.  If your provider uses 1995 Guidelines and you chose to use the 1997 Guidelines, you will need to help him/her with the transition and provide feedback on where to find the bullets in the EMR templates. Due to the constraints of the EMR, some providers only click a few boxes and it can lower the level of exam and possibly the overall E/M code.

For the following examples, we will use the 1995 Guidelines and the 1997 General Multi-System Examination Guidelines.   I do not use the 2 – 4 and 5 – 7 criteria for the EPF Exam vs. Detailed Exam for the 1995 exam.  I typically look at the amount of documentation relevant to the chief complaint.

Example #1

Constitutional – Well developed

Ears, Nose, Mouth and Throat – Tympanic membrane erythematous

Lymphatic – No cervical adenopathy

Cardio – No murmurs, gallops, or rubs

Psychiatric – Patient demonstrates the appropriate mood and affect

Audit with 1995 Guidelines (using the attached audit tool)

    • Constitutional
    • Ears, Nose, Mouth, and Throat
    • Hemic/Lymph/Immune
    • Cardio
    • Psych

The information listed is pretty limited and there is nothing in great detail.  I would give this exam an Expanded Problem Focused level.

Audit with 1997 Guidelines (using the attached audit tool)

    • Constitutional – 1 bullet for “Well developed”
    • Ears, Nose, Mouth, and Throat – 1 bullet for “Tympanic membrane erythematous
    • Lymphatic – No credit because the minimum requirement is “two or more areas”
    • Cardio – 1 bullet for “No murmurs, gallops or rubs”
    • Psych – 1 bullet for “Appropriate mood and affect”

I would give the exam a Problem Focused level based on the number of bullets (1 – 5).

Example #2

Weight:  #175  BP:  120/70  Temp:  98.6o

Eyes:  Conjunctivae clear, lids normal

Ears, Nose, Mouth, and Throat – Oral mucosa moist

Neck:  No masses

Respiratory:  Lungs clear to auscultation

Gastrointestinal:  Soft, non-tender, no hepatosplenomegaly, normal bowel sounds

Lymphatic:  No cervical adenopathy

Musculoskeletal:  Normal gait

Skin:  No lesions noted

Audit with 1995 Guidelines (using the attached audit tool)

    • Constitutional
    • Eyes
    • Ears, Nose, Mouth, and Throat
    • Neck (body area)
    • Respiratory
    • Gastrointestinal
    • Hemin/Lymph/Immune
    • Musculoskeletal
    • Skin

There are 8 organ systems documented so I would give credit for a Comprehensive exam.

Audit with 1997 Guidelines (using the attached audit tool)

    • Constitutional – 1 bullet for the 3 vital signs
    • Eyes – 1 bullet for “Conjunctivae clear, lids normal”
    • Ears, Nose, Mouth, and Throat – 1 bullet for “Oral mucosa moist”
    • Neck (body area) – 1 bullet for “No masses”
    • Respiratory – 1 bullet for “Lungs clear to auscultation”
    • Gastrointestinal – 1 bullet for “Soft, non-tender”  and 1 bullet for “No hepatosplenomegaly”
    • Hemic/Lymph/Immune - No credit because the minimum requirement is “two or more areas”
    • Musculoskeletal – 1 bullet for “Normal gait”
    • Skin – 1 bullet for “No lesions noted”

There are 8 bullets documented for an Expanded Problem Focused level. 

These are basic examples to show the different levels one may arrive at by using both sets of guidelines.  It takes time to get used to using the guidelines, but they will help you determine an appropriate level of service if utilized correctly.  As always, if you have any questions, you can email me @


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