Exam

There are 4 levels of exam:

a) “problem-focused,” typical of a 99212

b) “expanded-problem-focused,” typical of 99202 or 99213 office visits,

c) “detailed,” typical of 99203 or 99214 office visits, or

d) “comprehensive,” typical of level 99204, 99205, or 99215 office visits.

 

A problem focused exam contains 1-5 elements and is fitting for a 99212.

 

An expanded problem-focused exam contains 6-11 elements and is typical of a 99213 or 99202.

 

A detailed exam consists of at least 12 elements.   A detailed exam is typical of a 99214 or 99203.

 

A comprehensive exam should include at least 2 elements in each of at least 9 organ systems.  A comprehensive exam is typical of a 99215, 99204, or 99205.

 

An element is poorly defined, but generally understood as an inspection, palpation, percussion, or auscultation of one part of one organ system.  There are specific organ systems that are defined for the purposes of the exam.  Below is a list of the systems and examples of elements that could contribute to the exam:

 

1. General – (3 vital signs count as 1 element), general appearance
2. ENT – inspection of each EAC, inspection of each TM, inspection of pharynx, nasal inspection.
3. Eyes – fundiscopic exam, inspection of EOMI, inspection of pupils, inspection of anterior chambers, inspection of conjunctiva and lids.
4. Neck – trachea midline, thyroid normal
5. Cardiovascular – palpation of PMI, auscultation, inspection of edema, palpation of peripheral pulses.
6. Respiratory – chest inspection, percussion, auscultation, palpation.
7. GI – inspection, percussion, auscultation, palpation of abdomen.  Rectal exam.
8. GU – inspection of vulva, inspection of vagina and cervix, palpation of uterus, palpation of ovaries, testicular palpation, palpation of prostate, inspection of penis,
9. Breasts – breast inspection, breast palpation.
10. Musculoskeletal – inspection, palpation, range-of-motion of various joints
11. Skin – inspection and palpation of trunk, head, limbs.
12. Neuro – Cranial nerve evaluation, Reflexes, strength and sensation of limbs, cerebellar.
13. Psych – mood, affect, orientation, judgment, memory.
14. Lymphatic/Hematologic – lymph nodes of head, trunk, limbs.

 

Remember, for new office visits, one must meet the criteria for history, exam, and MDM.  For established office visits, one must only have two out of the three.