Practice Economics

Choose Your Exam Rules


Physicians only should perform patient examinations based upon the presenting problem and the standard of care. As mentioned in my previous column (April 2008, p. 21), the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) set forth two sets of documentation guidelines. The biggest difference between them is the exam component.

1995 Guidelines

The 1995 guidelines distinguish 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).

Further, these guidelines let physicians document their findings in any manner while adhering to some simple rules:

  • Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems; and
  • Elaborate on abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

Physician Alert

On Feb. 22, CMS issued written clarification for discharge day management services. Many Medicare contractors, consultants, and educators had been instructing physicians to report discharge day management services (CPT 99238-99239) only when the physician provides a face-to-face encounter with the patient. CMS confirmed this in Transmittal 1460 (Change Request 5794).

Additionally, CMS clarified when discharge day management can be reported ( Effective April 1:

  • The discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner, even if the patient is discharged from the facility on a different calendar date; and
  • The date of the pronouncement shall reflect the calendar date of service on the day it was performed, even if the paperwork is delayed to a subsequent date.

This second clarification varies from previous instruction that only allowed the physician to report 99238 or 99239 on the last day of the inpatient stay. Now, the physician can perform the necessary components and report discharge day management (e.g., final face-to-face visit with the patient, approve and/or the patient’s discharge, provide additional patient instruction as necessary) on the day before the patient leaves the facility. If physician documentation on the day prior to discharge does not include a statement about the patient’s discharge, it would be more appropriate to report subsequent hospital care (99231-99233).—CP

1997 Guidelines

The 1997 guidelines comprise bulleted items—referred to as elements—that correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.

For example, the physician only receives credit for documentation of vital signs (an element of the constitutional system) when three measurements are referenced (e.g., blood pressure, heart rate, and respiratory rate). Documentation that does not include three measurements or only contains a single generalized comment (e.g., vital signs stable) cannot be credited to the physician in the 1997 guidelines—even though these same comments are credited when applying the 1995 guidelines.

This logic also applies to the lymphatic system. The physician must identify findings associated with at least two lymphatic areas examined (e.g., “no lymphadenopathy of the neck or axillae”).

Elements that do not contain numeric criterion but identify multiple components require documentation of at least one component. For example, one psychiatric element involves the assessment of the patient’s “mood and affect.” If the physician comments that the patient appears depressed but does not comment on a flat (or normal) affect, the physician still receives credit for this exam element.

Code This Case

Minimum requirements not met: Upon admission to the hospitalist service, a 76-year-old male presents with hyperglycemia related to uncontrolled diabetes mellitus. Even though the hospitalist performed a complete exam, documentation only reflects an expanded problem-focused exam. What visit level can the hospitalist report for the initial inpatient (admission) service?

The Solution

An expanded problem-focused exam does not satisfy the minimum requirements for initial hospital care (99221). While some reviewers would say this service is not reportable (non-billable) since the minimum requirements were not met, some Medicare contractors allow the physician to report the service as an unlisted evaluation and management service (99499).

An unlisted code can represent many services not represented by another CPT code—therefore, a formal description and fee do not exist for unlisted codes. When reporting the service as 99499, manually add a description (e.g., initial hospital care with an EPF exam”) in the appropriate comment box on the electronic claim form, as well as a fee for the service. Unlisted codes also prompt the payer to initially suspend or reject the claim, pending review of the documentation. When requested, send all physician documentation surrounding the initial admission service.—CP

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Levels of Exam

There are four levels of exam, determined by the number of elements documented in the progress note (see Tables 1A and 1B, p. below).

As with the history component, the physician must meet the requirements for a particular level of exam before assigning it. The most problematic feature of the 1995 guidelines involves the “detailed” exam. Both the expanded problem-focused and detailed exams involve two to seven systems/areas, but the detailed exam requires an “extended” exam of the affected system/area related to the presenting problem. Questions surround the number of elements needed to qualify as an “extended” exam of the affected system/area.

Does “regular rate and rhythm; normal S1, S2; no jugular venous distention; no murmur, gallop, or rub; peripheral pulses intact; no edema noted” constitute an “extended” exam of the cardiovascular system, or should there be an additional comment regarding the abdominal aorta? This decision is left to the discretion of the local Medicare contractor and/or the medical reviewer.

Since no other CMS directive has been provided, documentation of the detailed exam continues to be inconsistent. More importantly, review and audit of the detailed exam remains arbitrary. Some Medicare contractors suggest using the 1997 requirements for the detailed exam, while others create their own definition and corresponding number of exam elements needed for documentation of the detailed exam. This issue exemplifies the ambiguity for which the 1995 guidelines often are criticized.

Meanwhile, the 1997 guidelines often are criticized as too specific. While this may help the medical reviewer/auditor, it hinders the physician. Physicians are frequently frustrated trying to remember the explicit comments and number of elements associated with a particular level of exam.

One solution is documentation templates. Physicians can use paper or electronic templates that incorporate cues and prompts for normal exam findings, incorporating adequate space to elaborate abnormal findings.

Remember the physician has the option of utilizing either the 1995 or 1997 guidelines, depending upon which set he perceives as easier to implement.

Additionally, auditors must review physician documentation using both the 1995 and 1997 guidelines, and apply the most favorable result to the final audit score.

Each type of evaluation and management service identifies a specific level of exam that must be documented in the medical record before the associated CPT code is submitted on a claim.

The most common visit categories provided by hospitalists and corresponding exam levels are outlined in Table 2 (above). Similar to the history component, other visit categories, such as critical care and discharge day management, do not have specified levels of exam or associated documentation requirements for physical exam elements. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

The 1997 Guidelines In Detail

Elements that physicians must document correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.


  • Measurement of any three of the following seven vital signs: sitting or standing blood pressure; supine blood pressure; pulse rate and regularity; respiration; temperature; height; and weight (may be measured and recorded by ancillary staff); and
  • General appearance of patient (development, nutrition, body habitus, deformities, attention to grooming).


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

Ears, Nose, Mouth, and Throat

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


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


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


  • Palpation of heart (location, size, thrills);
  • Auscultation of heart with notation of abnormal sounds and murmurs; and
  • Examination of carotid arteries (pulse amplitude, bruits); abdominal aorta (size, bruits); femoral arteries (pulse amplitude, bruits); pedal pulses (pulse amplitude); and extremities for edema and/or varicosities.

Chest (Breasts)

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

Gastrointestinal (Abdomen)

  • 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; and
  • -Obtain stool sample for occult blood test when indicated.



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


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

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


Palpation of lymph nodes in two or more areas:

  • Neck;
  • Axillae;
  • Groin; or
  • Other.


  • Examination of gait and station;
  • Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);
  • Examination of joints, bones and muscles of one or more of the following six areas: head and neck; spine, ribs and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity. The examination of a given area includes:
  • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;
  • Assessment of range of motion with notation of any pain, crepitation or contracture;
  • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and
  • Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.


  • Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers); and
  • Palpation of skin and subcutaneous tissue (induration, subcutaneous nodules, tightening).


  • Test cranial nerves with notation of any deficits;
  • Examination of deep tendon reflexes with notation of pathological reflexes (Babinski); and
  • Examination of sensation (by touch, pin, vibration, proprioception).


  • Description of patient’s judgment and insight; and
  • Brief assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (depression, anxiety, agitation).—CP

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