“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.
“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.
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 
I have reviewed the triage vital signs.
- Const: Well-nourished, Well-developed (WNWD), Young/Middle-Aged/Elderly Male/Female appearing stated age .
- Eyes: PERRL , no conjunctival injection , and symmetrical lids .
- ENMT: Atraumatic external nose and ears . Moist MM .
* Neck: Symmetric, trachea midline , No thyromegaly .
- CVS: +S1/S2, No murmurs or gallops . Peripheral pulses 2+ and equal in all extremities .
- RESP: Unlabored respiratory effort . Clear to auscultation bilaterally (CTAB) .
- GI: Nontender/Nondistended (NTND) , No hepatosplenomegaly (HSM) .
- MSK: Normocephalic/Atraumatic (NC/AT) , Extremities w/o deformity or ttp . No cyanosis or clubbing 
- Skin: Warm, Dry . No rashes or lesions .
- Neuro: CNs II-XII grossly intact . Sensation grossly intact .
- Psych: Awake, Alert, & Oriented (AAO) x3 . Appropriate mood and affect .
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.
- 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.
- 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:
- 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
- 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
- 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 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
- 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
- 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
- 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
- Inspection of skin & subcutaneous tissues: rashes, lesions, ulcers
- Palpation of skin & subcutaneous tissues: induration, nodules, tightening
- Cranial nerves w/ notation of deficits
- Deep tendon reflexes (DTRs) w/ notation of pathological reflexes (Babinski)
- Examination of sensation: touch, pin, vibration, proprioception
- Insight & judgement
- Brief assessment of mental status
- Orientation to time, place, & person
- Recent & remote memory
- Mood & affect: depression, anxiety, agitation
- Palpation of nodes in 2 or more areas: neck, axillae, groin, other
|1997 guidelines include two additional Organ Systems|
Chest (including breast and axillae)
|Body Areas – used by the 1995 Guidelines|
|Head (including face)|
Chest (including breast and axillae)
Genitalia, groin, buttocks
Back (including spine)
Extremity (each extremity counts as one body area)