E/M Code Calculator - by Components

Check all elements that are represented in the documentation: Location  Is pain diffuse or localized? Im-lateral or bilateral? Fixed or migratory? Radiating or referred? Duration  How long have symptoms been present? Timing  Is it nocturnal, diurnal or continuous? Is there a repetitive pattern? Quality  Is pain sharp, dull, throbbing, stabbing, constant or intermittent, acute or chronic, stable, improving or worsening? Severity  1-10, with 1 being no pain and 10 being the worst pain experienced. Context  What was pt doing when symptoms or signs began? What factors were present before / after? Modifying Factors  What does pt do for relief? What makes symptom(s) worse? What meds have been taken? What were results? Associated Signs & Symptoms  Additional sensations or feelings.

95 Guidelines - Body Areas

Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks

Back, including spine Right upper extremity Left upper extremity Right lower extremity Left lower extremity

Affected system was examined in detail

95 Guidelines - Organ Systems

Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal

Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic

Affected system was examined in detail

97 Guidelines - General Multi-system exam

Constitutional

Three vital signs General appearance

Eyes

Inspection of conjunctivae and lids Examination of pupils and irises (PERRLA) Ophthalmoscopic discs and posterior segments

Ears, Nose, Mouth, and Throat

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

Neck

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

Respiratory

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 the lungs

Cardiovascular

Palpation of the heart (location, size, thrills) Auscultation of the heart with notation of abnormal sounds and murmurs Assessment of lower extremities for edema and/or varicosities Examination of the carotid arteries (e.g., pulse amplitude, bruits) Examination of abdominal aorta (e.g., size, bruits) Examination of the femoral arteries (e.g., pulse amplitude, bruits) Examination of the pedal pulses (e.g., pulse amplitude)

Chest (Breasts)

Inspection of the breasts (e.g., symmetry, nipple discharge) Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)

Gastrointestinal (Abdomen)

Examination of the abdomen with notation of presence of masses or tenderness Examination of the liver and spleen Examination for the presence or absence of hernias Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool for occult blood testing when indicated

Genitourinary (Male)

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

Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures, which may include:

Examination of the external genitalia (e.g., general appearance, hair distribution, lesions) Examination of the urethra (e.g., masses, tenderness, scarring) Examination of the bladder (e.g., fullness, masses, tenderness) Examination of the cervix (e.g., general appearance, discharge, lesions) Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

Lymphatic

Palpation of lymph nodes - two or more areas:

Neck Axillae Groin Other

Musculoskeletal

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 the joints, bones, and muscles of one or more of the following six areas:

Area	a. Inspect/Palp	b. ROM	c. Stability	d. Strength/Tone
Head and neck
Spine, ribs, and pelvis
Right upper extremity
Left upper extremity
Right lower extremity
Left lower extremity

The examination of a given area may include:

1. Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
2. Assessment of range of motion with notation of any pain, crepitation or contracture
3. Assessment of stability with notation of any dislocation, subluxation, or laxity
4. Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any atrophy or abnormal movements

Skin

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

Neurologic

Test cranial nerves with notation of any deficits Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi) Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

Description of patient’s judgment and insight Brief assessment of mental status which may include:

1. orientation to time, place, and person
2. recent and remote memory
3. mood and affect

Results

95 Guidelines - Body Areas:  0  -  Organ Systems:  0

97 Guidelines - Bullets:  0  -  Organ Systems:  0