Editor’s Note (Jan 13, 2023):

The new AMA CPT 2023 Documentation Guidelines have been published and the prior physical elements are no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

“What do I see, hear, and smell when I walk into the room?” While the oral boards challenge you to perform the physical exam in a certain way, the day to day examination of patients can vary dramatically. Centers for Medicare and Medicaid Services (CMS), however, has physical exam guidelines for billing that conform to neither the exam you learned as a medical student nor the one you’ve refined as a resident. These disparities between what you do and how you’re asked to document it can lead to charts that are frequently down-coded or at risk if audited. The following discussion tries to unravel some of these twisted regulations and will provide tips and tricks on how to improve your physical exam documentation for coding and billing.

Double Standards

“There are no straight backs, no symmetrical faces, many wry noses, and no even legs. We are a crooked and perverse generation.” – Sir William Osler

There are 2 very different standards used to bill CMS and/or insurance companies: the 1995 and 1997 CMS guidelines. Overall, 1995 is too vague, 1997 is too specific, and the responsibility to choose one or the other falls on your coding department.

The 1995 guidelines identify Body Areas and Organ Systems as a framework for documenting the physical exam, but do not say what to chart under either.

The 1997 guidelines define mandatory physical exam elements and called them Bullets. A comprehensive exam requires all bulleted items to be examined, and at least 2 per system to be documented. The full list of bullets is in the appendix at the end of this post. These guidelines also describe Single Organ System examinations, which focus on a primary organ system but require bullets from other systems. Don’t bother looking these up– in general, a comprehensive single organ system examination is more complicated to perform and document than a comprehensive multi-system exam.

* 1995 guidelines allow a combination of systems & body areas for PF, EPF, & Detailed exams.  ** 1997 multi-system exam requires specific bullets for each system.

Work Smarter, Not Harder: Resuscitating the Physical Exam

• Develop a structured, comprehensive exam that you can perform on nearly any patient, and use the normal findings for this exam as your documentation template. If your department uses the 1997 guidelines, read through the bullets and pick 2 per system to include in your exam.
• Your examination is part of your decision making. The chief complaint will indicate certain positive or negative findings to be documented.
• With many EMRs, vital signs are usually automatically pulled into your note. In addition to reviewing all vitals as part of good patient care, include a statement in your documentation that the recorded vital signs were reviewed.

Sample template for normal comprehensive physical exam

Vital Signs: P / BP / RR / SpO2 / T [1]
I have reviewed the triage vital signs.

1. Const: Well-nourished, Well-developed (WNWD), Young/Middle-Aged/Elderly Male/Female appearing stated age [2].
2. Eyes: PERRL [1], no conjunctival injection [2], and symmetrical lids [3].
3. ENMT: Atraumatic external nose and ears [1]. Moist MM [2].
   * Neck: Symmetric, trachea midline [1], No thyromegaly [2].
4. CVS: +S1/S2, No murmurs or gallops [1]. Peripheral pulses 2+ and equal in all extremities [2].
5. RESP: Unlabored respiratory effort [1]. Clear to auscultation bilaterally (CTAB) [2].
6. GI: Nontender/Nondistended (NTND) [1], No hepatosplenomegaly (HSM) [2].
7. MSK: Normocephalic/Atraumatic (NC/AT) [1], Extremities w/o deformity or ttp [2]. No cyanosis or clubbing [3]
8. Skin: Warm, Dry [1]. No rashes or lesions [2].
9. Neuro: CNs II-XII grossly intact [1]. Sensation grossly intact [2].
10. Psych: Awake, Alert, & Oriented (AAO) x3 [1]. Appropriate mood and affect [2].

The 10 listed items are for both the 1995 and 1997 guidelines. The bracketed red numbers are the bullets for the 1997 guidelines. The * counts as a system/area in the 1997 guidelines.

Final Tips

• Although technically acceptable under 1995 guidelines, avoid charting only “normal” or “abnormal” under a system, instead list specific abnormal or pertinent normal findings.
• Find out which guidelines your coders use: the list of organ systems is mostly the same, but the 1997 rules require far more specific information.
• From an ethical and medical legal perspective, if you document it, examine it! Tailor your smart phrases or macros to a list of normals you reliably perform on every patient, every time, and include placeholders for you to add patient-specific information.
• If your department utilizes scribes (or incorporates medical student notes), take an extra second to review their documentation for completeness and accuracy.

Additional Reading

• Evaluation & Management Services Guide (August 2015, PDF)

[su_spoiler title=”Appendix: Full list of Organ Systems and Body Areas” style=”fancy” icon=”caret”]

The following 12 Organ Systems are the same in the 1995 and 1997 Guidelines, with the 1997 Bullets listed for each:

Constitutional

• Vital Signs (any 3 of the following): sitting or standing BP, supine BP, pulse rate & regularity, respiration, temperature, height, weight
• General Appearance, e.g. development, nutrition, body habitus, deformities, attention to grooming

Eyes

• Conjunctiva & Lids
• Pupils & Irises: size, symmetry, reaction to light, accommodation
• Ophthalmologic examination of optics discs and posterior segments

Ears, Nose, Mouth, Throat (ENMT)

• External inspection of ears and nose
• External auditory canal & tympanic membranes
• Assessment of hearing
• Nasal mucosa, septum, & turbinates
• Teeth, lips, & gums
• Oropharynx: mucosa, salivary glands, hard/soft palate, tongue, tonsils, posterior pharynx

Cardiovascular (CVS)

• Palpation: location (PMI), size, thrills
• Auscultation: heart sounds & murmurs
• Carotid arteries: pulses amplitude, bruits
• Abdominal aorta: size, bruits
• Femoral arteries: pulse amplitude, bruits
• Pedal pulses: pulse amplitude
• Extremities for edema and/or varicosities

Respiratory

• Respiratory effort, intercostal retractions, accessory muscle use, diaphragmatic movement
• Percussion of chest: dullness, flatness, hyperresonance
• Palpation of chest: tactile fremitus
• Auscultation of lungs: breath sounds, adventitious sounds, rubs

Gastrointestinal (GI)

• Abdominal masses or tenderness
• Liver & spleen
• Presence or absence of hernia
• Anus, perineum, rectum including sphincter tone, presence of hemorrhoids, rectal masses
• Obtain stool for fecal occult blood test (FOBT)

Genitourinary (GU) – Male

• Scrotal contents: hydrocele, spermatocele, tenderness of cord, testicular masses
• Penis
• Digital rectal exam (DRE) of prostate: size, symmetry, nodularity, tenderness

Genitourinary (GU) – Female

• External genitalia and vagina: general appearance, discharge, lesions, pelvic support, cystocele, rectocele
• Urethra: masses, tenderness, scarring
• Bladder: fullness, masses, tenderness
• Cervix: general appearance, lesions, discharge
• Uterus: size, contour, position, mobility, tenderness, consistency, descent or support
• Adnexa/parametria: masses, tenderness, organomegaly, nodularity

Musculoskeletal (MSK)

• Gait & station
• Inspection and/or palpation of digits and nails
• Joints, bones, muscles: one or more of the following 6 areas: head/neck, spine/ribs/pelvis, right upper extremity (RUE), left upper extremity (LUE), right lower extremity (RLE), left lower extremity (LLE)
  • Inspection and/or palpation: deformities, asymmetry, crepitus, tenderness, masses, effusions
  • Range of motion (ROM) w/ notation of pain, crepitus, contracture
  • Stability w/ notation of dislocation/luxation, subluxation, or laxity
  • Muscle strength & tone (flaccid, cog wheel, spastic) w/ notation of atrophy or abnormal movements

Skin

• Inspection of skin & subcutaneous tissues: rashes, lesions, ulcers
• Palpation of skin & subcutaneous tissues: induration, nodules, tightening

Neurologic

• Cranial nerves w/ notation of deficits
• Deep tendon reflexes (DTRs) w/ notation of pathological reflexes (Babinski)
• Examination of sensation: touch, pin, vibration, proprioception

Psychiatric

• Insight & judgement
• Brief assessment of mental status
  • Orientation to time, place, & person
  • Recent & remote memory
  • Mood & affect: depression, anxiety, agitation

Hem/Imm/Lymphatic

• Palpation of nodes in 2 or more areas: neck, axillae, groin, other

[/su_spoiler]

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have been published and the prior Review of Systems section is no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.”

This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

CMS Definition & Requirements

The ROS is “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced”. CMS recognizes the following organ systems* for ROS (1995 E/M Documentation Guidelines, PDF):

1. Constitutional
2. Eyes
3. Ears, Nose, Mouth, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (skin and/or breast)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic

*Organ systems: A complete ROS must document systems, not regions of the body. This is an important distinction, e.g. Eyes and ENMT count separately, but Head and HEENT don’t count.

You can document 4 types of ROS, depending on how many of the possible 14 systems are reviewed:

Work Smarter, Not Harder: Resuscitating ROS

How do you make this section useful?

• Offload pertinent positives and negatives from the HPI into ROS.
• Organize your history with HPI first, then ROS, and PFSH last (mimicking how CMS arranges the E/M guidelines) so you can document a concise HPI statement and move directly to ROS. This will make your charting efficient, yet effective and billable.
• Use the ROS as a cognitive backstop. As a junior resident documenting ROS, I often realized I had forgotten certain history questions, did not have enough information to exclude an item on my differential, or that something the patient said did not fit with the rest of the picture, prompting me to re-evaluate my differential.
• Have a quick, rehearsed set of ROS questions to cover any systems not included in the history. For example: Fevers? Vision/hearing changes? Sore throat? Chest pain? Shortness of breath? Vomiting or diarrhea? Painful urination? Rashes? Joint pain or swelling? Numbness or tingling? Changes in mood? Heat or cold intolerance? Bleeding or bruising? Allergic reactions? Tailor this question set to your practice setting and specific patients.

Final Tips

• One item– positive, negative, or normal– will suffice for each system.
• If you use dot phrases or macros, have a 2-4 system ROS for most patients and a complete ROS for patients that will reach E/M level 5. Consider also having a separate pediatric ROS.
• Always document at least 2 systems to prevent downcoding to an E/M level 2-3.
• ROS can be obtained by ancillary staff or by patient questionnaire, as long as the physician reviews and discusses any pertinent positives or negatives with the patient. Be sure to notate this in your documentation: “I have reviewed the ROS questionnaire and discussed the pertinent positives and negatives with the patient.” Also, initial any physical forms, e.g. patient questionnaires, which you have reviewed.
• A complete ROS can be a hybrid, listing pertinent positives and negatives by system, and then a notation indicating “All other systems are negative.”
• Both caveats used in the introduction are valid examples per CMS. If you give a number of systems in your caveat, you must list that number of systems afterwards, so the second version is more straightforward.