American College of Physicians: Internal Medicine — Doctors for Adults ®


Using the new E/M documentation guidelines, Part II

This month: documenting the physical exam and complexity of medical decision-making

From the December 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Sharon Mikolanis

Beginning Jan. 1, 1998, physicians will have to use new documentation guidelines when it comes to history-taking, examinations and medical decision-making. The new rules, which were developed jointly by HCFA and the AMA, will change the way physicians report and bill for evaluation and management (E/M) services.

Last month's article reviewed the documentation that physicians will need to document the medical history-taking portion of E/M services. (See " How to use the new E/M documentation guidelines " from the Nov. 1997 ACP Observer on ACP Online at This month's article will review the requirements for documenting physical examinations and medical decision-making. Directions on how to get the text of the new rules are available on ACP Online.

Documenting the exam

Levels of E/M services are based on four types of exam: problem focused, expanded problem focused, detailed and comprehensive. Levels of service are also based on the supporting documentation provided in the medical record.

Physicians can perform a general multi-system exam or one of several single-organ system exams. The type of exam—general vs. single—organ system exam—as well as content are selected by the physician based upon clinical judgment, the patient's history and the nature of the presenting problems.

Elements of the general multi-system exam are provided in the list Elements of the general multi-system examination, and identified by a mark. The chart, "Multi-system exam requirements," also contains information on the general multi-system exam.

There are also 11 single-organ system exams recognized by CPT. These are: cardiovascular; ears, nose, mouth, and throat; eyes; genitourinary (female); genitourinary (male); hematologic/lymphatic/immunologic; musculoskeletal; neurological; psychiatric; respiratory; and skin. If you perform these single-organ system exams, you should obtain a copy of the guidelines from HCFA to review the elements of the exam and the documentation requirements in more detail.

The following excerpts from the new rules provide additional advice:

  • "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."
  • "Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described."

Documentation of the complexity of medical decision-making

Levels of E/M services are based on four types of medical decision making: straightforward; low complexity; moderate complexity; and high complexity. (See "Elements that go into medical decision-making.") Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by three elements described below:

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

Generally, decision-making for a diagnosed problem is easier than for an identified but undiagnosed problem. The number and type of diagnostic tests used may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those that 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.

The following excerpts from the new rules offer additional advice:

  • "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 differential diagnoses or as a 'possible,' 'probable' or 'rule out' (R/O) diagnosis."

  • "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."

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

The following excerpts from the new rules offer additional advice:

  • "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, e.g., lab or X-ray, should be documented."
  • "The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as 'WBC elevated' or 'chest X-ray unremarkable' is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results."
  • "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."
  • "Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other source to supplement that obtained from the patient 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."
  • "The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented."

3. Risk of significant complication, 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/or the possible management options.

Because risk is complex and not easy to quantify, these examples may help you determine whether the risk of significant complications, morbidity, and/or mortality qualify as minimal, low, moderate, or high risk. The level of risk is based on the presenting problem(s), diagnostic procedures, and management options. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. Assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.

Minimal risk would apply to a patient who has a self-limiting or minor problem such as a sore throat requiring a throat exam with possible culture and recommendations for gargling, rest and increased fluid intake.

Low risk would cover a patient who has two or more self-limited problems, a stable chronic illness, or an acute uncomplicated illness or injury. Diagnostic procedures might include superficial needle biopsies, lab tests requiring arterial puncture, skin biopsies and non-cardiovascular imaging studies with contrast. Management options could include any one of the following: over-the-counter drugs, physical/occupational therapy and IV fluids without additives.

Moderate risk would apply to the patient who has one or more chronic illnesses with mild exacerbation, an undiagnosed new problem with uncertain prognosis, an acute illness with systemic symptoms, an acute complicated injury, or two or more stable chronic illnesses. Examples might include a patient with a lump in the breast, a head injury with brief loss of consciousness or colitis. Biopsies, cardiovascular imaging, diagnostic endoscopic procedures with no identified risk factors and physiologic tests under stress might be performed on patients at moderate risk. Management options could include any one of these: minor surgery; IV therapies; elective major surgery; prescription drug management; therapeutic nuclear medicine; and closed treatment of fractures or dislocation without manipulation.

High risk would apply to the patient who has one or more chronic illnesses with severe exacerbation, progression, side effects of treatment, acute/chronic illnesses or injuries that pose a threat to life or bodily function, or an abrupt change in neurologic status. Cardiovascular imaging studies with contrast, electrophysiological testing or diagnostic endoscopies with identified risk factors might be performed on patients at high risk. Management options could include any one of these: elective or emergency major surgery; use of parenteral controlled substances or drug therapy requiring toxicity measurement; and decisions not to resuscitate or to de-escalate care due to poor prognosis.

The chart ("Elements that go into medical decision-making ") shows what elements are required to qualify for one of the four E/M levels of medical decision-making (i.e., straightforward, low complexity, moderate complexity and high complexity). To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded (e.g., a limited diagnosis and a limited amount of data and minimal risk qualifies as low complexity decision making).

Sharon Mikolanis is Senior Associate for Payment Policy in ACP's Washington, D.C., office. She can be reached at 800-633-9400.

Multi-system exam requirements

The content and documentation requirements for general multi-system exams are listed below for each of the four exam types. For elements of these exams, see the list, next page.

Problem focused
Perform and document one to five elements identified by a in one or more organ system(s) or body areas.

Expanded problem
Perform and document at least six elements identified by a in one or more organ system(s) or body areas.

Include at least six organ systems or body areas. Perform and document at least two elements identified by a . Alternatively, perform and document at least 12 elements identified by a in two or more organ systems or body areas.

Include at least nine organ systems or body areas. For each system or area selected, all elements of the examination should be performed (unless directed otherwise) and at least two elements identified by a should be documented.

Elements of the general multi-system examination

The following list identifies elements of general multi-system exams by a .


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, and 7) weight. (May be measured and recorded by ancillary staff.)

General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming).


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

Ears, nose, mouth and throat

External inspection of ears and nose (e.g., overall appearance, scars, lesions, masses).
Otoscopic examination of external auditory canals and tympanic membranes.
Assessment of hearing (e.g., 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.


Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus).
Examination of thyroid (e.g., enlargement, tenderness, mass).


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


Palpation of heart (e.g., location, size, thrills).
Auscultation of heart with notation of abnormal sounds and murmurs.
Examination of:
Carotid arteries (e.g., pulse amplitude, bruits).
Abdominal aorta (e.g., size, bruits).
Femoral arteries (e.g., pulse amplitude, bruits).
Pedal pulses (e.g., pulse amplitude).
Extremities for edema and/or varicosities.

Chest (breasts)

Inspection of breasts (e.g., symmetry, nipple discharge).
Palpation of breasts and axillae (e.g., 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 of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses.
Obtain stool sample for occult blood test when indicated.


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

Pelvic examination (with or without specimen collection for smears and cultures), including:
Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele).
Examination of urethra (e.g., masses, tenderness, scarring).
Examination of bladder (e.g., fullness, masses, tenderness).
Cervix (e.g., general appearance, lesions, discharge).
Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support).
Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity).


Palpation of lymph nodes in two or more areas:



Examination of gait and station.
Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes).
Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs, and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and, 6) 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.
Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.


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


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


Description of patient's judgment and insight.
Brief assessment of mental status, including:
Orientation to time, place and person.
Recent and remote memory.
Mood and affect (e.g., depression, anxiety, agitation).

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