Physical Exam

Organ Systems and Body Parts are both included in the physical exam. An item can be included in either an Organ System or a Body Part, but the same item cannot be in both. One point is achieved when a System or Part is identified. Each System or Part is counted only once.

Body Parts:
1. Head (this includes sinuses)
2. Neck
3. Chest (including Breasts & Axillae)
4. Abdomen
5. Genitalia (Groin & Buttocks)
6. Back & Spine
7. Each Extremity (each extremity is counted once – up to 4 points in total)

Organ Systems: 

 1. Constitutional
One vital sign and general appearance of patient (Vitals taken by a MA should be dictated into the note. This acknowledges that they were reviewed.)

2. Eyes
conjunctivae & lids; PERRLA, EOMs intact; optic discs

3. Ears, Nose, Mouth, Throat
external ears and nose; ears and TM’s; hearing; nasal mucosa; septum & turbinates; lips, teeth, & gums; oropharynx

4. Cardiovascular

palpitation of heart; auscultation; carotids; abdominal aorta; femoral pulses; pedal pulses; extremities for edema &/or varicosities

5. Respiratory

respiratory effort; percussion; palpation; auscultation

6. Gastrointestinal
masses, tenderness; liver & spleen; hernia; anus, perineum & rectum; occult test

7. Genitourinary
Male: scrotal contents; penis; prostate gland
Female: external genitalia; urethra; bladder; cervix; uterus; adnexa/parametric

8. Musculoskeletal
gait & station; digit & nails; joints, bones, muscles of at least 1 area Extremities: left upper, right upper, left lower; tight lower, head, neck, spine, ribs, pelvis (exam should include inspection/palpation, ROM, stability, strength, tone)

9. Skin
inspection; palpation

10. Neuralgic
cranial nerves; reflexes; sensation

11. Psychiatric
Judgment & insight; orientation of time, place & person; memory; mood & affect

12. Hematologic/Lymphatic/Immunologic
lymph nodes in 2 or more areas: neck, axillary, groin, other

Coding Requirements:
                      Level 99202, 99212 requires at least 1
                      Level 99203, 99213 requires at least 2
                      Level 99204, 99214 requires at least 5
                      Level 99205, 99215 requires at least 9