E/M Weekly Tip: Examination

A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

References

• JJ Part B — Examination Component of 1995 and 1997 Documentation Guidelines
• JM Part B — Examination Component of 1995 and 1997 Documentation Guidelines
• Railroad Medicare — Examination Component of 1995 and 1997 Documentation Guidelines