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/Organ Systems (click here)

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

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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 (click here)

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

97 Guidelines - Cardiovascular exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Eyes

Inspection of conjunctivae and lids (e.g., xanthelasma)

Ears, Nose, Mouth, and Throat

Inspection of teeth, gums and palate Inspection of oral mucosa with notation of presence of pallor or cyanosis

Neck

Examination of jugular veins (e.g., distension; a, v or cannon a waves) Examination of thyroid (e.g., enlargement, tenderness, mass)

Respiratory

Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of the lungs (e.g., breath sounds, adventitious sounds, rubs)

Cardiovascular

Palpation of heart (eg, location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4 Auscultation of heart including sounds, abnormal sounds and murmurs Measurement of blood pressure in two or more extremities when indicated (eg, aortic dissection, coarctation) Examination of the carotid arteries (e.g., waveform, pulse amplitude, bruits, apical-carotid delay) Examination of the 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) Examination of the extremities for peripheral edema and/or varicosities

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness Examination of the liver and spleen Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Musculoskeletal

Examination of the back with notation of kyphosis or scoliosis Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

Extremities

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler’s nodes)

Skin

Inspection and/or palpation of skin and subcutaneous tissue (eg, stasis dermatitis, ulcers, scars, xanthomas)

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

97 Guidelines - Ear, Nose and Throat exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) Assessment of ability to communicate (eg, use of sign language or other communication aids) and quality of voice

Head and Face

Inspection of head and face (eg, overall appearance, scars, lesions and masses) Palpation and/or percussion of face with notation of presence or absence of sinus tenderness Examination of salivary glands Assessment of facial strength

Eyes

Test ocular motility including primary gaze alignment

Ears, Nose, Mouth and Throat

Otoscopic examination of external auditory canals and tympanic membranes including pneumo-otoscopy with notation of mobility of membranes Assessment of hearing with tuning forks and clinical speech reception thresholds (eg, whispered voice, finger rub) External inspection of ears and nose (eg, overall appearance, scars, lesions and masses) Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx (eg, asymmetry, lesions, hydration of mucosal surfaces) Inspection of pharyngeal walls and pyriform sinuses (eg, pooling of saliva, asymmetry, lesions) Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not required in children) Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children)

Neck

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

Respiratory

Inspection of chest including symmetry, expansion and/or assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Neurological/Psychiatric

Test cranial nerves with notation of any deficits

Brief assessment of mental status including: Orientation to time, place and person, Mood and affect (eg, depression, anxiety, agitation

97 Guidelines - Eye exam (click here)

Eyes

Test visual acuity (Does not include determination of refractive error) Gross visual field testing by confrontation Test ocular motility including primary gaze alignment Inspection of bulbar and palpebral conjunctivae Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma or infectious disease)

Ophthalmoscopic examination through dilated pupils (unless contraindicated) of Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages)

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person, Mood and affect (eg, depression, anxiety, agitation

97 Guidelines - Genitourinary exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Neck

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

Respiratory

Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

[See genitourinary (female)]

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness Examination for presence or absence of hernia Examination of liver and spleen Obtain stool sample for occult blood test when indicated

Genitourinary (MALE)

Inspection of anus and perineum

Examination (with or without specimen collection for smears and cultures) of genitalia including: Scrotum (eg, lesions, cysts, rashes) Epididymides (eg, size, symmetry, masses) Testes (eg, size, symmetry, masses) Urethral meatus (eg, size, location, lesions, discharge) Penis (eg, lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities)

Digital rectal examination including: Prostate gland (eg, size, symmetry, nodularity, tenderness) Seminal vesicles (eg, symmetry, tenderness, masses, enlargement) Sphincter tone, presence of hemorrhoids, rectal masses

Genitourinary (FEMALE)

Includes at least seven of the following eleven elements identified by bullets:

Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple discharge) Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses

Pelvic examination (with or without specimen collection for smears and cultures) including: External genitalia (eg, general appearance, hair distribution, lesions) Urethral meatus (eg, size, location, lesions, prolapse) Urethra (eg, masses, tenderness, scarring) Bladder (eg, fullness, masses, tenderness) Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) Cervix (eg, general appearance, lesions, discharge) Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) Anus and perineum

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Skin

Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)

Neurological/Psychiatric

Brief assessment of mental status including

Orientation to time, place and person, Mood and affect (eg, depression, anxiety, agitation

97 Guidelines - Hematologic/Lymphatic/Immunologic exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

Palpation and/or percussion of face with notation of presence or absence of sinus tenderness

Eyes

Inspection of conjunctivae and lids

Ears, Nose, Mouth and Throat

Otoscopic examination of external auditory canals and tympanic membranes Inspection of nasal mucosa, septum and turbinates Inspection of teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx)

Neck

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

Respiratory

Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen

Lymphatic

Palpation of lymph nodes in neck, axillae, groin, and/or other location

Extremities

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, ecchymoses, bruises)

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person, Mood and affect (eg, depression, anxiety, agitation

97 Guidelines - Musculoskeletal exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Cardiovascular

Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

Examination of gait and station

Examination of the joints, bones, and muscles/tendons of four of the following six areas:

Area	a. Inspect/Perc/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, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
2. Assessment of range of motion with notation of any pain (eg, straight leg raising), crepitation or contracture
3. Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
4. Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

NOTE: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element is counted separately for each body area. For example, assessing range of motion in two extremities constitutes two elements.

Extremities

[See musculoskeletal and skin]

Skin

Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, rashes, lesions, cafeau-lait spots, ulcers) in four of the following six areas: 1) head and neck; 2) trunk; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity.

NOTE: For the comprehensive level, the examination of all four anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremitites constitutes two elements.

Neurological/Psychiatric

Test coordination (eg, finger/nose, heel/ knee/shin, rapid alternating movements in the upper Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (eg, Babinski) Examination of sensation (eg, by touch, pin, vibration, proprioception)

Brief assessment of mental status including: Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

97 Guidelines - Neurological exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Eyes

Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

Cardiovascular

Examination of carotid arteries (eg, pulse amplitude, bruits) Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Musculoskeletal

Examination of gait and station

Assessment of motor function including: Muscle strength in upper and lower extremities Muscle tone in upper and lower extremities (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (eg, fasciculation, tardive dyskinesia)

Extremities

[See musculoskeletal]

Neurological

Evaluation of higher integrative functions including Orientation to time, place and person Recent and remote memory Attention span and concentration Language (eg, naming objects, repeating phrases, spontaneous speech) Fund of knowledge (eg, awareness of current events, past history, vocabulary)

Test the following cranial nerves: 2nd cranial nerve (eg, visual acuity, visual fields, fundi) 3rd, 4th and 6th cranial nerves (eg, pupils, eye movements) 5th cranial nerve (eg, facial sensation, corneal reflexes) 7th cranial nerve (eg, facial symmetry, strength) 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or finger rub) 9th cranial nerve (eg, spontaneous or reflex palate movement) 11th cranial nerve (eg, shoulder shrug strength) 12th cranial nerve (eg, tongue protrusion)

Examination of sensation (eg, by touch, pin, vibration, proprioception) Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes (eg, Babinski) Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)

97 Guidelines - Psychiatric exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Musculoskeletal

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements Examination of gait and station

Psychiatric

Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (eg, perseveration, paucity of language) Description of thought processes including: rate of thoughts; content of thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation Description of associations (eg, loose, tangential, circumstantial, intact) Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions Description of the patient’s judgment (eg, concerning everyday activities and social situations) and insight (eg, concerning psychiatric condition)

Complete mental status examination including Orientation to time, place and person Recent and remote memory Attention span and concentration Language (eg, naming objects, repeating phrases) Fund of knowledge (eg, awareness of current events, past history, vocabulary) Mood and affect (eg, depression, anxiety, agitation, hypomania, lability)

97 Guidelines - Respiratory exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Ears, Nose, Mouth and Throat

Inspection of nasal mucosa, septum and turbinates Inspection of teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx)

Neck

Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) Examination of jugular veins (eg, distension; a, v or cannon a waves)

Respiratory

Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

Auscultation of heart including sounds, abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements Examination of gait and station

Extremities

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person, Mood and affect (eg, depression, anxiety, agitation

97 Guidelines - Skin exam (click here)

Constitutional

Measurement of any three of the following seven vital signs:

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Eyes

Inspection of conjunctivae and lids

Ears, Nose, Mouth and Throat

Inspection of lips, teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx)

Neck

Examination of thyroid (eg, enlargement, tenderness, mass)

Cardiovascular

Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Gastrointestinal (Abdomen)

Examination of liver and spleen Examination of anus for condyloma and other lesions

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Extremities

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:

Head, including the face and Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back Right upper extremity Left upper extremity Right lower extremity Left lower extremity

NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements.

Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person, Mood and affect (eg, depression, anxiety, agitation

Results

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

97 Guidelines - Bullets:  0  -  Organ Systems:  0