The physical examination is the objective portion of the patient encounter. The extent of the examination performed is determined by the patient’s medical condition and the nature of the current illness as recorded in the history.
There are four levels of examination:
Expanded problem focused
There are two documentation guidelines: 1995 and 1997
Recognize 7 body areas and 11 organ systems
It is important to record the specific details of all abnormal or variant findings. Notations of “negative” or “normal” are acceptable for documenting findings related to any unaffected area or asymptomatic organ system.
Each level of examination has certain requirements for documentation:
Problem focused: one body area and/or organ system exam
Expanded problem focused: Limited two to seven body area and/or organ system exam
Detailed: an extended two to seven body area and/or organ system exam
Comprehensive: at least eight system exam. Does not use body areas and/or systems.
An accurately documented examination will allow for better quality of care, will help to establish the medical necessity of your service and allow for correct code selection.