You may follow either the 1995 or 1997 guidelines in determining the appropriate level of service. In comparing the guidelines, changes to 1997 are as follows:
- History - In 1997, an extended HPI includes the status of at least three chronic or inactive conditions. This is the only change.
- Examination - In 1995, only the multi-system examination was defined. In 1997, the documentation requirements for the multi-system exam have changed (see chart below) and ten single organ system examinations have been developed.
- Decision Making - No changes
General Multi-System Examination
| Type of Examination | 1995 | 1997 |
| Problem Focused |
Limited exam, affected area/system (one) |
One to five bullets |
| Expanded Problem Focused |
Two to seven systems |
At least six bullets |
| Detailed |
Two to seven systems (more detail) |
At least two bullets from each of the six areas or at least 12 bullets in two or more areas |
| Comprehensive |
Eight or more systems |
Perform all bullets in at least nine areas and document at least two bullets from each of the nine areas |
1995 - For purposes of examination, the following body areas are recognized:
- Head, including the face
- Neck
- Chest, including breasts and axillae
- Abdomen
- Genitalia, groin, buttocks
- Back, including spine
- Each extremity
1995 and 1997 - For purposes of examination, the following organ systems are recognized:
- Constitutional (e.g., vital signs, general appearance)
- Eyes
- Ears, nose, mouth and throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Skin
- Neurologic
- Psychiatric
- Hematologic/lymphatic/immunologic