In the E/M documentation guidelines, what does "more detail" regarding the exam mean, and what is the difference between an expanded problem-focused exam and detailed exam?

Answer:
The 1995 body systems expanded problem-focused exam requires documentation of the affected body system plus one through six other body systems. The 1995 body areas expanded problem-focused exam requires documentation of the affected body area plus one through six other body areas.

The 1995 body systems detailed exam requires documentation of two through seven body systems with more detail. The 1995 body areas detailed exam requires documentation of two through seven body areas with more detail.

"More detail" refers to the extent of the exam. The level of detail involved in an exam is a clinical judgment based on the documentation for each individual medical record. There is an expectation that the exam will be more involved, and therefore more documentation would be submitted for a detailed exam. The documentation for a detailed exam would consist of at least two findings for at least two body areas or two organ systems.

Example:

  • Abdomen: soft, nontender, BSx4
  • Respiratory: Lung CTA, no wheezing or rhonchi

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