Chapter 23
Evaluation & Management

23.1 Prolonged Physician Services

Payment will be allowed for procedure codes 99354 (prolonged physician service in the office or other outpatient setting; first hour), 99355 (prolonged physician service in the office or other outpatient setting; each additional 30 minutes), 99356 (prolonged physician service in the inpatient setting; first hour), and 99357 (prolonged physician service in the inpatient setting; each additional 30 minutes) when the following criteria are met:
The physician has furnished and billed one of the procedure codes listed in column 1 as well as the corresponding code(s) in column 2 for the patient on the same day.
Office or other Outpatient Setting:

99354		99201 - 99205 99212 - 99215 99241 - 99245
99355	-	99354 plus one of the codes required for 99354

  Inpatient Setting:

99356		99221 - 99223 99231 - 99233 99251 - 99255 99261 - 99263 99301 - 99303 99311 - 99313
99357	-	99356 plus one of the codes required for 99356

The time counted toward payment for prolonged evaluation & management services included only direct face-to-face contact between the physician and the patient (whether or not the service was continuous).
The medical record documents the content of the evaluation and management service code, the duration and content of prolonged services that the physician personally furnished after the typical time of the evaluation & management service has been exceeded by at least 30 minutes. Documentation need not be submitted to the carrier for processing purposes.
Following are examples of correct reporting of prolonged physician services with direct patient contact in an office setting. The number in parentheses following the code represents the number of units reported for the code:

 

Duration of Prolonged Services	Code to Report
Less than 30 minutes	Not reported separately
30 - 74 minutes	99354 (1)
75 - 104 minutes	99354 (1) and 99355 (1)
105 - 134 minutes	99354 (1) and 99355 (2)
135 - 164 minutes	99354 (1) and 99355 (3)
165 - 194 minutes	99354 (1) and 99355 (4)

23.2 Physician Care Plan Oversight Services

In general, Medicare continues to consider care plan oversight services to be included in the payment for other services. However, Medicare allows separate payment for care plan oversight services under the following conditions:

• The beneficiary must require complex or multi-disciplinary care modalities requiring ongoing physician involvement in the patient’s plan of care;
• The beneficiary must be receiving Medicare covered home health or hospice services during the period in which the care plan oversight services are furnished
• The physician who bills CPO must be the same physician who signed the home health or hospice plan of care;
• The physician must furnish at least 30 minutes of care plan oversight within the calendar month for which payment is claimed and no other physician has been paid for care plan oversight within that calendar month;
• The physician must have provided a covered physician service that required a face-to-face encounter (codes 99201-99263, 99281-99357) with the beneficiary within the 6 months immediately preceding the provision of the first care plan oversight service (a face-to-face encounter does not include EKG, lab services or surgery);
• The care plan oversight billed must not be routine post-operative care provided in the global surgical period of a surgical procedure billed by the physician;
• The care plan oversight services must be personally furnished by the physician who bills them;
• Services provided “incident to” a physician’s service do not qualify as CPO and do not count toward the 30-minute requirement;
• The physician may not bill CPO during the same calendar month in which (s)he bills the Medicare monthly capitation payment (90918-90925) (ESRD benefit) for the same beneficiary;
• The physician billing for Care Plan Oversight must document in the patient’s record which services were furnished and the date and length of time associated with those services.
• If the above conditions are met, Medicare will:
• Allow payment to one physician per patient per month for care plan oversight if it involves 30 or more minutes of the physician’s time per calendar month.
• Allow payment for 30 or more minutes of care plan oversight to a physician providing post-surgical care during the post-operative period only if the care plan oversight is documented to be unrelated to the surgery and billed with modifier 24.

a. Payment to Medical Directors of Home Health Agencies for Care Plan Oversight

Medical Directors of home health agencies can bill for care plan oversight if they meet the following criteria:

Medical Directors may bill for this service if:

They do not have significant ownership in or a significant financial relationship with the home health agency.

• Significant ownership is defined as:

1. having a direct or indirect ownership interest of 5 percent or more in the capital, stock, or the profits of the home health agency.

2. having an ownership interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation that is secured by the agency, if that interest equals 5 percent or more of the agency's assets.

• Significant financial or contractual relationship is defined as:

1. receiving any compensation as an officer or director (i.e., board of directors) of the home health agency.

2. having direct or indirect business transactions with the home health agency, in any year, amount to more than $25,000 or 5 percent of the agency's total operating expenses, whichever is less. Business transactions mean contracts, agreements, purchase orders, or leases to obtain services supplies, equipment, and space.

Note: If you would like additional information, please refer to Section 424.22 of the Code of Federal Regulations.

No separate payment will be allowed for care plan oversight services to physicians who have a significant ownership interest in, or a significant financial or contractual relationship with, a home health agency (HHA). For hospice patients, payment will only be made to the attending physician. Payment will not be made for care plan oversight services furnished by the hospice medical director, even if he/she is the patient's attending physician, or to physician who are employees of or providing services under arrangement with the hospice,

b. Volunteer Hospice Medical Directors

Volunteer hospice medical directors cannot bill for physician care plan oversight services. Section 418.3 of the Code of Federal Regulations (CFR) states that a volunteer within a hospice is considered an employee of the hospice. Payments to the hospice already include payment for services of the hospice physicians in establishing and overseeing the plans of care. Separate Part B payments are limited to physicians that are not affiliated with the hospice (see CFR 418-304). Thus, the volunteer medical director is considered an employee of the hospice and can not bill separately for care plan oversight under the physician fee schedule.

c. Services that are not Medically Necessary

Although a Regional Home Health Intermediary has approved payment for either home health or hospice care, this does not automatically mean that care plan oversight can be billed. The care plan oversight services must be of a type and duration for which separate payment is warranted. At least 30 minutes of the physician's time must be spent in medically necessary activities of the type described by CPT code 99375. Participation of a beneficiary in covered hospice or home health care does not alone qualify the beneficiary's physician for separate payment of care plan oversight services.

d. Questions and Answers

Some physicians have raised the following questions concerning care plan oversight services.

Q1. What physician activities are considered care plan oversight services for which separate payment is allowed?

A1. Care plan oversight includes the following physician activities: development or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan, and/or adjustment of medical therapy. Care plan oversight does not include the routine pre-and post-service work associated with visits and procedures. Also, telephone calls with patients and/or their families are not included.

Q2. What documentation is required?

A2. Physicians claiming payment for care plan oversight services must document in their records the care plan oversight services they furnish, including the dates and exact duration of time spent on the services for which payment is claimed. Care plan oversight is recognized by Medicare as a physician service and must be provided and documented only by the responsible physician.

Q3. How will beneficiaries know that they may be responsible for additional coinsurance payments for care plan oversight services?

A3. Since care plan oversight services do not typically involve a face-to-face encounter between the patient and the physician, the patient may not be aware that the services were provided. Physicians can help by informing their patients that Medicare will pay for these services when the specified conditions are met. Beneficiaries will also be notified regarding allowed care plan oversight services in their Explanation of Your Medicare Part B Benefits messages.

23.3 Inpatient Dialysis and Evaluation/Management

Payment for Evaluation and Management (E&M) procedure codes 99231-99233 and 99261-99263 will be bundled into payment for inpatient dialysis procedures 90935-90947 for services rendered on or after January 1, 1995. No payment will be made for the E&M visits if billed the same day as inpatient dialysis.

23.4 Initial Evaluation and Management Procedure Codes

Initial hospital care codes (99221-99223) are used to report the first hospital inpatient encounter with the patient by the admitting physician. Only one initial hospital evaluation and management (E&M) procedure code (i.e., 99221-99223) may be reported per hospital stay. Subsequent evaluation and management services should be reported by using the appropriate subsequent hospital care procedure code (i.e., 99231-99233).

For initial inpatient encounters by physicians other than the admitting physician, the subsequent hospital care codes (99231-99233) or the initial inpatient consultation codes (99251-99255) should be reported as appropriate.

When more than one initial hospital evaluation and management procedure code is reported during a single hospital stay only one initial hospital E&M will be allowed. The remainder of the initial hospital E&M services will be denied as incorrect reporting. These subsequent hospital care services may be resubmitted with the appropriate subsequent hospital care procedure codes (99231-99233).

a. Routine Physical Exam

A physician may bill Medicare beneficiaries for the non-covered portion of a physical exam performed in conjunction with a covered visit. When a physician furnishes a routine physical exam as well as a medically indicated or covered visit during the same encounter, the covered visit is viewed as being provided in lieu of a part of the routine physical. The physician may charge the beneficiary (as a charge for the non-covered portion of the routine physical) the difference between the physician's current established charge for the routine physical and his/her current established charge for the covered visit. It should be noted that the covered portion of the routine physical exam, which is billed with an established evaluation and management code, is subject to the limiting charge.

The physician is not required to give the beneficiary written advance notice of non-coverage because Medicare coverage of routine physical examinations is denied on the basis of the statutory exclusion.

The preventive services codes (99381-99397) should be used to report the non-covered portion of the visit. Providers are encouraged to file a claim for these services if the Medicare beneficiary wishes a Medicare determination of coverage either for supplemental insurance purposes or if the patient believes the service may be covered, despite advice to the contrary from the physician.

23.5 Critical Care (CPT Codes 99291 and 99292)

a. Definition of Critical Illness or Injury

The AMA’s CPT has redefined a critical illness or injury as follows:

“A critical illness or injury acutely impairs one or more vital organ systems such that the patient’s survival is jeopardized.”

Note: The term “unstable” is no longer used in the CPT definition to describe critically ill or injured patients.

b. Definition of Critical Care Services

CPT 2000 has redefined critical care services as follows:

“Critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient. The care of such patients involves decision making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration. It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient’s condition continues to require the level of physician attention described above.”

“Critical care services include but are not limited to, the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post operative complications, or overwhelming infection. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.”

The following procedures are to be bundled into the payment of critical care (99291 and 99292) when provided on the same day, by the same physician administrating the critical care:
Code Description

• 36000 Introduction of needle or intracatheter, vein
• 36410 Venipuncture, child over age 3 years or adult, necessitating physician’s skill (separate procedure), for diagnostic or therapeutic purposes. Not to be used for routine venipuncture
• 36600 Arterial puncture, withdrawal of blood for diagnosis
• 71010 Radiologic examination, chest; single view, frontal
• 71015 Radiologic examination, chest; stereo, frontal
• 71020 Radiologic examination, chest, two views, frontal and lateral
• 90846 Family psychotherapy (without the patient present)
• 91105 Gastric intubation, and aspiration or lavage for treatment (e.g., for ingested poisons)
• 92953 Temporary transcutaneous pacing
• 93561 Indicator dilution studies such as dye or thermal dilution, including arterial and/or venous catheterization; with cardiac output measurement (separate procedure)
• 93562 ...subsequent measurement of cardiac output
• 94656 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day
• 94657 ...subsequent days
• 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management*
• 94662 Continuous negative pressure ventilation (CNP), initiation and management *
• 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination
• 94762 ...by continuous overnight monitoring (separate procedure)
• 99090 Analysis of information data stored in computers (e.g., ECGs, blood pressures, hematologic data)
• G0001 Routine ventipuncture for collection of specimen(s)

c. Guidelines for Use of Critical Care Codes

In order to reliably and consistently determine that delivery of critical care services rather than other evaluation and management services is medically necessary, both of the following medical review criteria must be met in addition to the CPT definitions:

• Clinical Condition Criterion

There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.

• Treatment Criterion

Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.

Providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill. The physician service must be medically necessary and meet the definition of critical care services as described previously in order to be considered covered.

EXAMPLE: A dermatologist treating a rash on an ICU patient who is maintained on a ventilator and nitroglycerine drip which are being managed by an intensivist should not bill for critical care.

d. “Full Attention” Requirement For Critical Care Service

Constant attendance is no longer a prerequisite for use of critical care codes. Critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

e. Reporting of Physician Time Toward Critical Care Time

CPT 2000 states the following: “Time spent with the individual patient should be recorded in the patient’s record. The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside. Also, when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the medical decision making.”

“Time spent in activities that occur outside of the unit or off the floor (e.g., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit (e.g., participation in administrative meetings or telephone calls to discuss other patients).”

f. Medical Review Guidelines Regarding “Full Attention” and Physician Time in Critical Care Services.

• Since critical care is a time-based code, the physician’s progress note must contain documentation of the total time involved providing critical care services.
• Time involved performing procedures that are not bundled into critical care (i.e., billed separately) may not be included and counted toward critical care time. The physician’s progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time.
• Time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options may be counted toward critical care time only when

a) the patient is unable or incompetent to participate in giving a history and/or making treatment decisions,
b) the discussion is absolutely necessary for treatment decisions under consideration that day, and
c) all of the following are documented in the physician’s progress note for that day:

(i) the patient was unable or incompetent to participate in giving history and/or making treatment decisions, as appropriate,
(ii) the necessity of the discussion (e.g., no other source was available to obtain a history” or “because the patient was deteriorating so rapidly needed to discuss treatment options with family immediately”),
(iii) the treatment decisions for which the discussion was needed, and
(iv) the substance of the discussion as related to the treatment decision.

The physician’s progress note must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day.

All other family discussions, no matter how lengthy, may not be counted towards critical care time. Examples of family discussions which do not meet the appropriate criteria include:

• Regular or periodic updates of the patient’s condition,
• Emotional support for the family, and
• Answering questions regarding the patient’s condition (only questions related to decision-making regarding treatment, as described above, may be counted toward critical care).

Telephone calls to family members and surrogate decision makers must meet the same conditions as face-to-face meetings.

• Time involved in activities that do not directly contribute to the treatment of the patient, and therefore may not be counted towards critical care time, include teaching sessions with residents whether conducted on rounds or in other venues.

g. Non Critically Ill or Injured Patients in a Critical Care Unit

Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes
This means that the care of a patient who receives medical care in a critical care, intensive care, or other specialized care unit should not be reported with critical care codes unless the services:

• meet the CPT definition of critical illness/injury,
• meet the CPT definition of critical care services, and
• meet the guidelines defined above.

Examples of patients who may not satisfy Medicare criteria for critical care payment include:

• patients admitted to a critical care unit because no other hospital beds were available,
• patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs,
• patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin drips) to be administered in the critical care unit.

Care of patients which does not meet all these criteria should be reported using the appropriate evaluation and management codes (e.g., subsequent hospital visit codes 99231 - 99233, or inpatient consultation codes 99251 - 99255) depending on the level of service provided.

h. Hours And Days Of Critical Care That May Be Billed

Critical care time may be continuous or interrupted.

• Critical care time of less than 30 minutes is not reported separately. This should be reported using another appropriate E/M code.
• CPT code 99291 is used to report the first 30 to 74 minutes of critical care on a given date of service. This code may be reported only one time per calendar date, even if the time spent by the physician is not continuous.
• CPT code 99292 is used to report each additional 30 minutes beyond the 74 minutes. It may also be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes may not be reported separately.
• A physician must be prepared to demonstrate that the service billed meets the definition of critical care.
• Carriers may request supporting documentation at any time for any claim (e.g., requesting additional information when more than a total of 12 hours of critical care is billed by a physician for one or more patients on the same day). A carrier may also request documentation whenever there is an indication that the services may not have been critical care.
• Only one physician may bill for a given hour of critical care even if more than one physician is providing care to a critically ill patient.

i. Global Surgery

Use of modifier “-25” to permit payment of critical care on the day of a procedure with a global fee period.

Services with a 0, 10, or 90 day global period such as endotracheal intubation (CPT code 31500) cardiopulmonary resuscitation (CPT code 92950) the insertion, and placement of a flow directed catheter e.g., Swan-Ganz, (CPT code 93503) are not bundled into the critical care codes. Separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier “-25”. The time spent performing these unbundled services, e.g., endotracheal intubation, is excluded from the determination of the time spent providing critical care.

j. Teaching Physician Rules for Critical Care Billing

For procedure codes determined on the basis of time, such as critical care, the teaching physician must be present for the period of time for which the claim is made. For example, payment will be made for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes.

Time spent teaching may not be counted towards critical care time. Time spent by the resident in the absence of the teaching physician cannot be billed by the teaching physician as critical care. Only time spent by the resident and teaching physician together with the beneficiary or the teaching physician alone with the beneficiary can be counted toward critical care time.

k. Ventilator Management

The Medicare Physician Fee Schedule final rule, published on December 10, 1993, established national policy of paying for either an E/M service or ventilator management but not both. The final rule states, “We will continue to recognize the ventilator management codes (CPT codes 94656, 94657, 94660, and 94662) as physician services payable under the physician fee schedule. Physicians will no longer be paid for ventilation management in addition to an evaluation and management service, even if the evaluation and management service is billed with CPT modifier “-25”.”

23.6 "Incident To" Services

Medicare defines "incident to" services as those services and supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. In other words, these services do not represent the major portion of the overall service provided to a beneficiary by the physician. To be covered incident to the services of a physician, services and supplies must be:

• An integral, although incidental, part of the physician's professional service;
• Commonly rendered without charge or included in the physician's bill;
• Of a type that is commonly furnished in physicians' offices or clinics
• Furnished under the physician's direct personal supervision; and
• Furnished by the physician or by an individual who qualifies as an employee of the physician.

a. Commonly Furnished in Physicians' Offices

Services and supplies commonly furnished in physicians' offices are covered under the incident to provision. Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.

Supplies usually furnished by the physician in the course of performing his/her services, e.g., gauze, ointments, bandages, and oxygen are also covered. Charges for such services and supplies must be included in the physicians' bills. To be covered, supplies, including drugs and biologicals, must represent an expense to the physician. For example, where a patient purchases a drug and the physician administers it, the cost of the drug is not covered.

b. Direct Personal Supervision
Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision. This applies to services of auxiliary personnel employed by the physician and working under his or her supervision, such as nurses, nonphysician anesthetists, psychologists, technicians, therapists, including physical therapists, and other aides. Thus, where a physician employs auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician's service if:

• there is a physician's service rendered initially to which the services of such personnel are an incidental part, and
• there is direct personal supervision by the physician.

b.1 Office Setting

Direct personal supervision in the office setting does not mean that the physician must be physically present in the same room with the auxiliary personnel. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services. Availability of the physician by telephone does not constitute direct personal supervision.

b.2 Outside the Office Setting

Outside the office setting (e.g., in a patient's home or in a nursing facility), direct personal supervision requires the physician to have face-to-face contact with the patient and to be in the room while the auxiliary personnel is rendering the service. The physician must remain with the patient and auxiliary personnel for the duration of the treatment. The availability of the physician by telephone and the presence of the physician somewhere in the institution does not constitute direct personal supervision. (See special instructions further in this section regarding homebound patients in medically underserved areas).

When a physician has an office within a nursing home or other institution, services performed by employees of the physician outside the "office" area must be directly supervised by the physician. The services of a physician's nonphysician employee can be covered in this circumstance only if the physician accompanies the nonphysician to treat the patient and directly supervises the nonphysician services for the duration of the treatment. The physician's presence in the "office" or other area of the institution does not suffice to meet this requirement. As with all services, payment for services rendered in an office established within an institution, must be reasonable and necessary for the individual patient's condition.

b.3 Hospital Services

Section 1862(a)(14) of the Social Security Act provides that every service to hospital inpatients and outpatients, except for the professional services of physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists, as well as qualified psychologist services must be provided by the hospital directly, or by others under arrangements made by the hospital, and only the hospital may bill its Medicare intermediary for the services. If the services are not provided and billed for in this way, they are not covered by Medicare. This is sometimes referred to as the hospital "bundling" provision. This provision is applicable to all hospital patients where a Medicare payment can be made to the hospital, including patients in psychiatric hospitals.

This means that services and supplies that would normally be covered "incident to" in an office setting, such as the services of nurses and other clinical assistants that physicians hire and supervise, are not billable by the physician in hospital settings. Physicians must personally perform the service in order for it to be payable in a hospital setting.

c. Employment

To be considered an employee for purposes of this section, the nonphysician performing an incident to service may be a part-time, full-time, or leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician (hereafter referred to collectively as the physician or other entity) who provides personal supervision (as described below). A leased employee is a nonphysician working under a written employee leasing agreement which provides that:

• The nonphysician, although employed by the leasing company, provides services as the leased employee of the physician or other entity; and
• The physician or other entity exercises control over all actions taken by the leased employee with regard to the rendering of medical services to the same extent as the physician or other entity would exercise such control if the leased employee were directly employed by the physician or other entity.

In order to satisfy the employment requirement, the nonphysician (either leased or directly employed) must be considered an employee of the supervising physician or other entity under the common law test of an employer/employee relationship specified in §210(j)(2) of the Act, 20 CFR 404.1007, and §RS 2101.102 of the Retirement and Survivors Insurance part of the Social Security Program Operations Manual System.

Services provided by auxiliary personnel not in the employ of the physician, physician group practice, or other legal entity, even if provided on the physician's order or included in the physician's bill are not covered as incident to a physician's service since the law requires that the services be of kinds commonly furnished in physicians' offices and commonly either rendered without charge or included in physicians' bills. As with the physicians' personal professional service, the patient's liability for the incidental services is to the physician, physician group practice, or other legal entity. Therefore, the incidental service must represent an expense incurred by the physician or other entity responsible for providing the service.

d. Nonphysician Practitioner Services

Certain nonphysician practitioners, licensed by the state under various programs to assist or act in the place of the physician may also have their services covered incident to the services of a physician. These nonphysician practitioners include the following: certified nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.

Services performed by these nonphysician practitioners incident to a physician's professional services can include not only services ordinarily rendered by a physician's office staff person (e.g., medical services such as taking blood pressures, temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient's condition.

A nonphysician practitioner, such as a physician assistant or a nurse practitioner, may be licensed under state law to perform a specific medical procedure. This practitioner may be able to perform the procedure without direct physician supervision and have the service separately covered and paid for by Medicare as a physician assistant's or nurse practitioner's service. However, in order to have the same service covered as "incident to" the services of a physician, it must be performed under the direct personal, supervision of the physician as an integral part of the physician's personal in-office service. There must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent service by the physician of a frequency that reflects the physicians' continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.

e. Physician Directed Clinics

Services and supplies incident to a physician's service in a physician directed clinic or group association are generally the same as those described above.

A physician directed clinic is one where (a) a physician (or a number of physicians) is present to perform medical (rather than administrative) services at all times the clinic is open; (b) each patient is under the care of a clinic physician; and (c) the nonphysician services are under medical supervision.

In highly organized clinics, particularly those which are departmentalized, direct personal physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service. Therefore, services performed by therapists and other aides are covered even though they are performed in another department of the clinic.

Supplies provided by the clinic during the course of treatment are also covered. When the auxiliary personnel perform services outside the clinic premises, the services are covered only if performed under the direct personal supervision of a clinic physician. If the clinic refers a patient for auxiliary services performed by personnel who are not employed by the clinic, such services are not considered "incident to" a physician's service.

f. Other Nonphysician Providers Who May Bill for Services Incident To

Besides physicians, the Medicare law also provides coverage for services rendered incident to the services of other practitioners. These practitioners are as follows:

• Nurse Practitioner
• Nurse Midwife
• Physician's Assistant
• Clinical Psychologist
• Physical Therapist/Occupational Therapist
• Clinical Nurse Specialist
• Audiologist

All criteria applicable to incident to services of a physician as described in this chapter are also applicable to services billed incident to the services of these nonphysician practitioners.

g. Billing Requirements for Incident to Services

Effective January 1, 1997, services provided `incident to' the personal professional services of a physician or nonphysician must be billed using the YR modifier in addition to any other applicable modifiers. Failure to use the modifier may subject the payments of these incorrectly billed claims to recoupment.

YR - services performed by another provider but billed as services performed `incident to' the personal professional services of the billing physician/nonphysician.

Services rendered incident to the services of a physician or nonphysician provider are reported and paid as though the physician/nonphysician provider personally performed the service. Although there are instances when the provider and the provider's employee collaborate on a service, the YR modifier should be reported with service codes when the employee performed the service predominantly without the provider's collaboration. Do not use this modifier when reporting laboratory tests, supplies, drugs, or biologicals. The YR modifier should not be used with codes which are typically not physician services, including:

• All procedures codes billed with a TC modifier.
• A0021-A0999, A4190-A9505, B4034-B9999, D0210-D9999, E0100-E1830, G0001-G0027, G0050-G0060, J0120-J9999, K0001-K0412, L0100-L9999, P2028-P9615, Q0034-Q0081, Q0083-Q0085, Q0091, Q0092, Q0111-Q9940, R0070-R0076, V2100-V5299.
• 36430, 70010-79999, 80002-89399, 90780-90784, 90788, 92325, 92326, 92977, 94640-94652, 94664-94668, 95004, 95024, 95044-95056, 95115, 95117, 96400, 96408-96425, 96520, 96530, 96900-96913, 99175, 99185, 99186, 99195.

h. General Supervision for Homebound Patients in Medically Underserved Areas

In some medically underserved areas, there are only a few physicians available to provide services over broad geographic areas or to a large patient population. The lack of medical personnel (and, in many instances, a home health agency servicing the area) significantly reduces the availability of certain medical services to homebound patients. Some physician and physician-directed clinics, therefore, call upon nurses and other paramedical personnel to provide these services under general (rather than direct) supervision.

Medicare provides coverage for individual or intermittent services listed below when they are performed by personnel meeting any pertinent state requirements (e.g., a nurse, a technician, or physician extender) and where the criteria listed below are met:

• The patient is homebound, i.e., confined to his home. Physicians who supervise care for homebound patients must certify in the patient's records that the patient is homebound as well as the length of time the condition is expected to last.
• The service is an integral part of the physician's service to the patient (thus the patient must be one the physician is treating) and is performed under general supervision by employees of the physician or clinic. General supervision means that the physician need not be physically present at the patient's place of residence when the service is performed; however, the service must be performed under the physician'soverall supervision and control. The physician orders the service(s) to be performed and contact is maintained between the nurse or other employee and the physician, e.g., the employee contacts the physician directly if additional instructions are needed, and the physician must retain professional responsibility for the service. All other "incident to" requirements must be met.
• The services are included in the physician's/clinic's bill and he/she has incurred an expense for them.
• The services of the paramedical are required for the patient's care; that is they are reasonable and necessary.

This coverage should not be considered as an alternative to home health benefits where there is a participating home health agency (HHA) in the area which could provide the needed services on a timely basis. Intermittent services (at least one every 60 days) for injection and venipuncture to homebound patients are usually not covered if the services are available from a HHA. In some instances, services under the supervision of a physician/clinic to homebound patients may be covered even though the services of an HHA are available to the area. Examples of such situations are:

1. Where the patient has exhausted home health benefits.

2. Where the HHA could not respond on a timely basis, or

3. Where the physician could not have foreseen that intermittent services would be needed, e.g., and more services are necessary.

The doctor's medical records for patients receiving these services must be appropriately documented and available for the carrier's review when requested.

Covered Services: Where the requirements mentioned above are met, the following services are eligible for homebound patients rendered under general supervision:

• Injections
• Venipuncture
• EKGs
• Therapeutic exercises
• Insertion and sterile irrigation of a catheter
• Changing of catheters and collection of catheterized specimen for urinalysis and culture
• Dressing changes
• Replacement and/or insertion of nasogastric tubes
• Removal of fecal impaction, including enemas
• Sputum collection for gram stain and culture, and possible acid-fast and/or fungal stain and culture
• Paraffin bath therapy for hands and/or feet in rheumatoid arthritis or osteoarthritis
• Teaching and training the patient for:

(a) the care of colostomy and ileostomy
(b) the care of permanent tracheostomy
(c) testing urine and care of the feet (diabetic patients only)
(d) blood pressure monitoring

Teaching and training services (also referred to as educational services) can be covered only where they provide knowledge essential for the chronically ill patient's participation in his own treatment and only where they can be reasonably related to such treatment or diagnosis. Educational services that provide more elaborate instruction than is necessary to achieve the required level of patient education are not covered. After essential information has been provided, the patient should be relied upon to obtain additional information for himself or herself.

Note: Please reference Medicare Medical Policy Bulletins (MMPB) Z-27 and Z-33 for additional information on Supervision Guidelines and Employment Relationship Criteria.

23.7 Documentation Guidelines for Evaluation & Management Services

These guidelines have been developed jointly by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA). Our mutual goal is to provide physicians and claims reviewers with advice about preparing or reviewing documentation for Evaluation and Management (E/M) services. In developing and testing the validity of these guidelines, special emphasis was placed on assuring that they:

• are consistent with the clinical descriptors and definitions contained in CPT,
• would be widely accepted by clinicians and minimize any changes in record-keeping practices, and
• would be interpreted and applied uniformly by users across the country.

This edition contains a substantial amount of new material and a number of significant revisions in material that appeared in the first edition. Because of the extensive changes, the section on examination should be read in its entirety. In this edition:

• The content of general multi-system examinations has been defined with greater clinical specificity.
• Documentation requirements for general multi-system examinations have been changed.
• For the first time, content and documentation requirements have been defined for examinations pertaining to ten organ systems. The content of these examinations was developed with the assistance of representatives from the specialties that frequently perform these examinations.
• Several editorial changes have been made in the definitions of the four types of examinations. This text also appears in CPT itself in the section headed "Evaluation and Management (E/M) Services Guidelines," but the revisions will not appear there until the 1999 edition of CPT.
• The definition of an extended history of present illness has been expanded to include information about chronic or inactive conditions.

The AMA and HCFA wish to thank the CPT Editorial Panel, the CPT Advisory Committees, the Practicing Physicians Advisory Council, and the Medicare Contractor Medical Directors for their thoughtful advice, comments and direction concerning the many complex issues that were addressed in the development of these guidelines. The AMA and HCFA are committed to continually improving these guidelines and welcome comments based on their usage.

a. What is documentation and Why is it Important?

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

• the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her health care over time.
• communication and continuity of care among physicians and other health care professionals involved in the patient's care;
• accurate and timely claims review and payment;
• appropriate utilization review and quality of care evaluations; and
• collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

b. What Do Payers Want and Why?

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

• the site of service;
• the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or
• that services provided have been accurately reported.

c. General Principles of Medical Record Documentation

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

a. reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

b. assessment, clinical impression or diagnosis;

c. plan for care; and

d. date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

d. Documentation of E/M Services

The following information provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counseling or coordination of care. The three key components-history, examination, and medical decision making-appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. While some of the text of CPT has been repeated in this subsection, refer to your CPT for complete descriptors for E/M services and instructions for selecting a level of service. Documentation guidelines are identified by the symbol  DG.

The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:

• history;
• examination;
• medical decision making;
• counseling;
• coordination of care;
• nature of presenting problem; and
• time.

The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.

Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (eg, examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.

These Documentation Guidelines for E/M services reflect the needs of the typical adult population. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area.

As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, the content of a pediatric examination will vary with the age and development of the child. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.

e. Documentation of History

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

• Chief complaint (CC);
• History of present illness (HPI);
• Review of systems (ROS); and
• Past, family and/or social history (PFSH).

The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is dependent upon clinical judgement and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels.)

Documentation Elements (example)
 
 

History of Present Illness (HPI)	Review of Systems  (ROS)	Past, Family,and/or Social History (PFSH)	Type of History
Brief	N/A	N/A	Problem Focused
Brief	Problem Pertinent	N/A	Expanded Problem Focused
Extended	Extended	Pertinent	Detailed
Extended	Complete	Complete	Comprehensive

 

• DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.
• DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re- recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:
  • describing any new ROS and/or PFSH information or noting there has been no change in the information; and
  • noting the date and location of the earlier ROS and/or PFSH.
• DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
• DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

Definitions and specific documentation guidelines for each of the elements of history are listed below.

e.1 Chief Complaint (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words.

• DG: The medical record should clearly reflect the chief complaint.

e.2 History of Present Illness (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

• location;
• quality;
• severity;
• duration;
• timing;
• context;
• modifying factors, and
• associated signs and symptoms.

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI.

• DG: The medical record should describe one to three elements of the present ill ness (HPI).

An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.

• DG: The medical record should describe at least four elements of the present illness (HPI), or the status of at least three chronic or inactive conditions.

e.3 Review of Systems (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized:

• Constitutional symptoms (e.g., fever, weight loss)
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

• DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.

• DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

• DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

e.4 Past, Family and/or Social History (PFSH)

The PFSH consists of a review of three areas:

• past history (the patient's past experiences with illnesses, operations, injuries and treatments);
• family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and
• social history (an age appropriate review of past and current activities).

For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories are subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

• DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH.

• A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.

  • DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency depart ment; domiciliary care, established patient; and home care, established patient.

• DG: At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient.

f. Documentation of Examination

The levels of E/M services are based on four types of examination:
 

• Problem Focused a limited examination of the affected body area or organ system.
• Expanded Problem Focused a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).
• Detailed an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
• Comprehensive a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).

These types of examinations have been defined for general multi-system and the following single organ systems:

• Cardiovascular
• Ears, Nose, Mouth and Throat
• Eyes
• Genitourinary (Female)
• Genitourinary (Male)
• Hematologic/Lymphatic/Immunologic
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Skin

A general multi-system examination or a single organ system examination may be performed by any physician regardless of specialty. The type (general multi-system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgement, the patient's history, and the nature of the presenting problem(s).

The content and documentation requirements for each type and level of examination are summarized below and described in detail in the tables. In the tables, organ systems and body areas recognized by CPT for purposes of describing examinations are shown in the left column. The content, or individual elements, of the examination pertaining to that body area or organ system are identified by bullets () in the right column.

Parenthetical examples, "(eg, ...)", have been used for clarification and to provide guidance regarding documentation. Documentation for each element must satisfy any numeric requirements (such as "Measurement of any three of the following seven...") included in the description of the element. Elements with multiple components but with no specific numeric requirement (such as "Examination of liver and spleen") require documentation of at least one component. It is possible for a given examination to be expanded beyond what is defined here. When that occurs, findings related to the additional systems and/or areas should be documented.
 

• DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient.
• DG: Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
• DG: 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).

f.1 General Multi-System Examinations

General multi-system examinations are described in detail. To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:
 

• Problem Focused Examination - should include performance and documentation of one to five elements identified by a bullet () in one or more organ system(s) or body area(s).
• Expanded Problem Focused Examination - should include performance and documentation of at least six elements identified by a bullet () in one or more organ
  system(s) or body area(s).
• Detailed Examination - should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet () is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet () in two or more organ systems or body areas.
• Comprehensive Examination - should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet () should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.

f.2 Single Organ System Examinations
The single organ system examinations recognized by CPT are described below . Variations among these examinations in the organ systems and body areas identified in the left columns and in the elements of the examinations described in the right columns reflect differing emphases among specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met:
 

• Problem Focused Examination - should include performance and documentation of one to five elements identified by a bullet (), whether in a box with a shaded or unshaded border.
• Expanded Problem Focused Examination - should include performance and documentation of at least six elements identified by a bullet (), whether in a box with a shaded or unshaded border.
• Detailed Examination - examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet (), whether in a box with a shaded or unshaded border.
  Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (), whether in a box with a shaded or unshaded border.

Comprehensive Examination - should include performance of all elements identified by a bullet,  whether in a shaded or unshaded box. Documentation of every element in a box with a shaded border and at least one element in a box with an unshaded border is expected.

f.3 Content and Documentation Requirements

a. General Multi-System Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height,7) weight (May be measured and recorded by ancillary staff)  General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Eyes	Inspection of conjunctivae and lids  Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry)  Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
Ears, Nose,  Mouth and Throat	External inspection of ears and nose (eg, overall appearance, scars, lesions, masses)  Otoscopic examination of external auditory canals and tympanic membranes  Assessment of hearing (eg, whispered voice, finger rub, tuning fork)  Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums  Examination of oropharynx: oral mucosa, salivary glands, hard  and soft palates, tongue, tonsils and posterior pharynx
Neck	Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)  Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory	Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)  Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
Cardiovascular	Palpation of heart (eg, location, size, thrills) Auscultation of heart with notation of abnormal sounds and  murmurs  Examination of:  carotid arteries (eg, pulse amplitude, bruits)  abdominal aorta (eg, size, bruits)  femoral arteries (eg, pulse amplitude, bruits)  pedal pulses (eg, pulse amplitude)  extremities for edema and/or varicosities
Chest (Breasts)	Inspection of breasts (eg, symmetry, nipple discharge)  Palpation of breasts and axillae (eg, masses or lumps, tenderness)
Gastrointestinal  (Abdomen)	Examination of abdomen with notation of presence of masses or tenderness  Examination of liver and spleen  Examination for presence or absence of hernia  Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated
Genitourinary	MALE:   Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)  FEMALE:  Pelvic examination (with or without specimen collection for smears  and cultures), including:    Examination of external genitalia (eg, general appearance,hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)  Examination of urethra (eg, masses, tenderness, scarring)  Examination of bladder (eg, fullness, masses, tenderness)  Cervix (eg, general appearance, lesions, discharge)  Uterus (eg, size, contour, position, mobility, tenderness,  consistency, descent or support)  Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
Lymphatic	Palpation of lymph nodes in two or more areas:  Neck  Axillae  Groin  Other
Musculoskeletal	Examination of gait and station Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)  Examination of joints, bones and muscles of one or more of the following  six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity.The examination of a given area includes:  Inspection and/or palpation with notation of presence of any misalignment,  asymmetry, crepitation, defects, tenderness, masses, effusions  Assessment of range of motion with notation of any pain, crepitation or  contracture  Assessment of stability with notation of any dislocation (luxation),  subluxation or laxity  Assessment of muscle strength and tone (eg, flaccid, cogwheel, spastic)  with notation of any atrophy or abnormal movements
Skin	Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)  Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)
Neurologic	Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski) Examination of sensation (eg, by touch, pin, vibration, proprioception)
Psychiatric	Description of patient's judgment and insight Brief assessment of mental status including:  orientation to time, place and person  recent and remote memory  mood and affect (eg, depression, anxiety, agitation)

Contents and Documentation Requirements

Level of Exam	Perform and Document:
Problem Focused	One to five elements identified by a bullet.
Expanded Problem Focused	At least six elements identified by a bullet.
Detailed	At least two elements identified by a bullet from each   of six areas/systems OR at least twelve elements  identified by a bullet in two or more areas/systems.
Comprehensive	Perform all elements identified by a bullet in at least   nine organ systems or body areas and document at least   two elements by a bullet from each of the nine areas/ systems.

b. Cardiovascular Examination

System/Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs:1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Head and Face
Eyes	Inspection of conjunctivae and lids (eg, xanthelasma)
Ears, Nose,  Mouth and Throat	Inspection of teeth, gums and palate Inspection of oral mucosa with notation of presence of pallor or cyanosis
Neck	Examination of jugular veins (eg, distension; a, v or cannon a waves)  Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory	Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)  Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
Cardiovascular	Palpation of heart (eg, location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4)  Auscultation of heart including sounds, abnormal sounds and murmurs  Measurement of blood pressure in two or more extremities when indicated (eg, aortic dissection, coarctation) Examination of:  Carotid arteries (eg, waveform, pulse amplitude, bruits,  apical-carotid delay)  Abdominal aorta (eg, size, bruits)  Femoral arteries (eg, pulse amplitude, bruits)  Pedal pulses (eg, pulse amplitude)  Extremities for peripheral edema and/or varicosities
Chest (Breasts)
Gastrointestinal  (Abdomen)	Examination of abdomen with notation of presence of masses or tenderness  Examination of liver and spleen Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy
Genitourinary (Abdomen)
Lymphatic
Musculoskeletal	Examination of the back with notation of kyphosis or scoliosis  Examination of gait with notation of ability to undergo exercise  testing and/or participation in exercise programs  Assessment of muscle strength and tone (eg, flaccid, cog wheel,  spastic) with notation of any atrophy and abnormal movements
Extremities	Inspection and palpation of digits and nails (eg, clubbing, cyanosis,  inflammation, petechiae, ischemia, infections, Osler's nodes)
Skin	Inspection and/or palpation of skin and subcutaneous tissue  (eg, stasis dermatitis, ulcers, scars, xanthomas)</