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?

"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.

1995 Exam Documentation Guidelines 

Expanded problem focused exam
A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
Detailed exam
An extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Resource: CMS MLN Evaluation and Management Services Guide

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC


National Supplier Clearinghouse MAC


RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries



Click to Chat Now