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Our progress note form, pocket guide and quick-reference list will help you put the revised Medicare documentation guidelines into practice.

Fam Pract Manag. 1998;5(1):29-41

As we've explained in our last two issues, the revised Medicare documentation guidelines from HCFA necessitate significant changes in the way you document exams. The Jan. 1 enforcement date has been postponed, however.

At press time, HCFA has granted a request from the AMA to extend the grace period by six months, to July 1. The random, prepayment medical reviews of E/M codes that HCFA has planned will use both the original guidelines and the revised guidelines until that date. As many as 3 percent of E/M claims may be subject to review.

Briefly, here's how the guidelines for exam documentation have changed: Under the original guidelines, the level of exam depended on the number of organ systems and body areas you examined and documented in the medical record. The revised guidelines go much farther, identifying the clinical elements that constitute comprehensive multisystem and single-organ-system exams and establishing precisely how many of those elements must be performed and documented to substantiate each level of exam. To further complicate matters, the number of systems and body areas recognized by HCFA in the exam guidelines has changed, from 19 to 14. (No, the human anatomy hasn't changed — just HCFA's view of it.) The changes mean that in addition to counting the systems and body areas you examine, now you must also count the number of clinical elements you perform and document for each of those systems and body areas.

Yes, the revised guidelines are confusing, but time, practice and, we hope, our articles on the subject will help you to make sense of them. Here we offer three tools designed to help you implement the guidelines.

1. The progress note form

The first tool is a revised version of a form that we first published in 1995, when the original documentation guidelines were introduced. The checklist is designed to make it easier to count systems and body areas. We've revised the list of systems and body areas to match those that HCFA now recognizes for the general multisystem exam, and we've done some rearranging to allow more room for the note. To count clinical elements (referred to as “bulleted elements” in the guidelines), you'll have to work through your note.

To use the checklist, put a check mark in the appropriate column for every system you cover in the ROS, every area of the PFSH you touch on and every system or body area you examine. In circumstances where you would normally write, for example, “GI normal” with no further elaboration, a check mark in the “nl” column should suffice. Remember that the guidelines still require that you note explicitly any negative responses on the ROS and negative findings on the exam that are relevant to the presenting problem.

You should be able to quickly determine the number of systems covered in the ROS and the number of areas covered in the PFSH by counting the check marks in those sections of the form. Before you can determine the level of history, you'll also need to count the elements of the HPI that appear in the note. The elements of the HPI are listed on the form to help you remember what to look for. (Note that the HPI has a new element now, too: “status of chronic diseases.” It's important to track how many such diseases you ask about.)

To determine the level of exam, you'll be able to count the number of systems and body areas by counting check marks. Then you'll need to compare your note with the exam chart developed by HCFA and the AMA and count the number of clinical elements in the note. (The pocket guide and quick-reference list discussed later in this article both include a version of the general multisystem exam chart.)

Note that the form provides no checklist for documenting medical decision making; to assess that, you'll need to refer to your note.

Like the original, this form also provides a shortcut for documenting encounters dominated by counseling or coordination of care. Simply check the box labeled “Couns/coord > 50%” (i.e., “Counseling and/or coordination of care took more than 50 percent of the visit”), enter the total time (face-to-face or floor time, as appropriate) of the encounter and the time devoted to counseling and/or coordination of care, and describe in the note the counseling and/or activities to coordinate care that you provided.

2. The pocket guide

You'll find a revised version of our original “Pocket Guide to the Documentation Guidelines” facing page 89 of the print issue. Before you continue reading this article, you may want to remove the pocket guide along the perforation, cut out the shaded areas and fold the guide as indicated in the instructions.

With the pocket guide folded correctly, the front should show the two Code selection tables at the top with a History table below. The words Exam and Decision making should be showing above the history table, each next to the head of a broad gray arrow. The gray arrow in the History table indicates that the History table contributes information to the History column of the code selection tables. Open the first flap and on the right you should see an Exam table with a gray arrow indicating its relationship to the Exam column of the Code selection tables. Lift up the small flap carrying the exam table and you should see a two-column table that lists the clinical content of the comprehensive general multisystem exam as it's defined in the new documentation guidelines. (We chose to include the general multisystem exam because of its prevalence in family medicine.) Close the small flap, open the third flap, and you should see three tables that contribute information to the Decision making table and a gray arrow indicating the relationship of decision making to the Code selection tables.

Keep in mind that the pocket guide is designed to jog your memory, not to teach you everything you need to know about the guidelines. To consult the unabridged version of the tables or the requirements for single-system exams, you'll need to refer to the guidelines themselves.

While the checklist form described earlier is designed to help you as you write or dictate your note, the pocket guide is intended to help you determine the appropriate code, based on what you have documented in the note. You might want to consult the pocket guide before coding a visit, but you'll probably find it more useful as a way of fine-tuning your “seat of the pants” coding. If you use it to help you in a self-audit from time to time, checking the codes you've submitted for selected visits, you can identify areas where you may be coding too high or too low.

Let's use the pocket guide to evaluate the following sample note, which represents a common type of Medicare visit — the routine follow-up visit for a patient with multiple chronic problems and no new complaints:

  • S: Mr. Doe returns today for a routine four-month F/U for evaluation and management of his NIDDM, hypertension and OA. No new complaints. He denies headache, visual changes, chest pain, SOB or extremity numbness. No increased joint pain. Dietary compliance good, and his BP and home glucose monitoring records indicate acceptable control of both.

  • O: CONST: BP 138/84, Wt 175, P 82 and regular.

  • HEENT: PERRLA, EOMI; EACs and TMs nl; oropharynx benign.

  • NECK: supple w/o JVD, bruits or thyromegaly.

  • RESP: bs clr to P and A w/o retractions or rubs.

  • HEART: WNL w/o gallop, murmur, rub, click or irregularity.

  • EXT: distal pulses intact w/o cyanosis, clubbing or edema.

  • NEURO: deep tendon reflexes WNL and symmetric; no decreased lower extremity sensation noted.

  • LABS: FBS 132, UA WNL.

  • A: 1. Stable NIDDM

    2. Stable hypertension

    3. Stable osteoarthritis

  • P: 1. Glucotrol 5 mg daily q.a.m.

    2. Procardia XL 30 mg daily.

    3. Relafen 1,000 mg daily.

    4. Continue home glucose monitoring.

    5. SMA-7 and glycosylated hemoglobin today.

    6. RTC for routine F/U in 4 months.

If you've read the other two articles in this series, you ought to be able to use the pocket guide to evaluate this note and come up with a suggested coding level. Before we go on, you might want to re-read the note and decide how to code it without consulting the pocket guide or the guidelines, then read on to compare your analysis with ours.

History: The History table on the front of the pocket guide doesn't include a column for chief complaint, since that is required for all levels of history and not likely to be missing from any progress note. Even though the patient in our example has no new complaints, there is a chief complaint in the first sentence of the note. The guidelines define chief complaint very broadly as a statement “describing the symptom, problem, condition, diagnosis, physicianrecommended return or other factor that is the reason for the encounter” (emphasis added).

Determining how to score the HPI in this note would have been difficult under the original guidelines, since the patient has no new complaints to characterize. Now that HCFA has redefined the extended HPI as four or more elements of the HPI or the status of three or more chronic conditions, the HPI score is clear. Because the patient is returning for a routine evaluation of three chronic diseases — diabetes, hypertension and osteoarthritis — the HPI is extended.

The ROS includes questions about at least six systems and body areas: eyes, cardiovascular, respiratory, musculoskeletal, neurologic and endocrine. The History table of the pocket guide, then, tells us that the ROS is detailed.

Because the note doesn't really touch on past, family or social history, there is no PFSH. Consequently, although the HPI and ROS seem to point to a detailed history, the actual level is limited to expanded problem focused. As the History table indicates, expanded problem focused is the highest level possible without a PFSH. Note that simply reviewing the patient's medication list and documenting that fact in the note would have counted as past history, therefore raising the PFSH to detailed and, therefore, the overall level of history to detailed.

Exam: Opening the first flap of the pocket guide exposes on the right the table devoted to the exam, and on the back of the small flap is the table that lists the clinical content of the comprehensive general multisystem exam. The sample note documents findings for eight systems and body areas, which, as the table indicates, meets the requirement for a detailed exam, provided that at least 12 bulleted elements are documented in the note.

Here's how the note and the bulleted elements in the general multisystem exam table match up:

  • Constitutional: Measurement of any three of the following seven vital signs ... (“BP 138/84, Wt 175, P 82 and regular”);

  • Eyes: Examination of pupils and irises (HEENT: “PERRLA, EOMI”);

  • ENT/mouth: Examination of oropharynx (HEENT: “throat clr, oropharynx benign w/o pallor”);

  • ENT/mouth: Otoscopic examination of external auditory canals and tympanic membranes (HEENT: “EACs and TMs nl”);

  • Neck: Examination of neck (NECK: “supple w/o JVD, bruits or thyromegaly”);

  • Neck: Examination of thyroid (NECK: “supple w/o JVD, bruits or thyromegaly”);

  • Respiratory: Assessment of respiratory effort (RESP: “bs clr to P and A w/o retractions or rubs”);

  • Respiratory: Auscultation of lungs (RESP: “bs clr to P and A w/o retractions or rubs”);

  • Respiratory: Percussion of chest (RESP: “bs clr to P and A w/o retractions or rubs”);

  • Cardiovascular: Auscultation of heart with notation of abnormal sounds and murmurs (HEART: “WNL w/o gallop, murmur, rub, click or irregularity”);

  • Cardiovascular: Examination of pedal pulses (EXT: “distal pulses intact w/o cyanosis, clubbing or edema”);

  • Cardiovascular: Examination of extremities for edema and/or varicosities (EXT: “distal pulses intact w/o cyanosis, clubbing or edema”);

  • Musculoskeletal: Inspection and/or palpation of digits and nails (EXT: “distal pulses intact w/o cyanosis, clubbing or edema”);

  • Neurologic: Examination of deep tendon reflexes with notation of pathological reflexes (NEURO: “deep tendon reflexes WNL and symmetric”);

  • Neurologic: Examination of sensation (NEURO: “no decreased lower extremity sensation noted”).

In addition to noting the exam of eight systems and body areas, the sample note documents a total of 15 bulleted elements, clearly making the exam detailed.

Medical decision making: Because the history and the exam differ in level and this is an established-patient visit, the level of medical decision making will determine the level of the visit. As the Code selection tables indicate, the level of the visit is determined by the highest two of the three components. Open the pocket guide fully, and we'll use the decision making tables to evaluate the note.

First, the score for number of diagnoses and management options involved works out to be 3: No new problems are reported, and each established, previously diagnosed problem (diabetes, hypertension and osteoarthritis) counts for one point because they're all stable. Second, in evaluating the amount and complexity of data to be reviewed, we have only lab tests to consider. That gives a score of 1 (the guidelines say no matter how many tests of a given class are requested or reviewed, the note earns no more than one point per class). Finally, the level of risk seems to be moderate, both because the visit involves prescription drug therapy and because it concerns three stable chronic illnesses. Because the level of decision making is determined by the highest two of the three components, the level for this encounter is moderate complexity.

To review, then, we have an expanded problem-focused history, a detailed exam and moderately complex decision making to evaluate on the Code selection table at the top of the pocket guide; because two of the three are enough to determine the level for an established-patient visit, we end up with a code of 99214.

The new guidelines for documenting exams make coding E/M visits even more complicated than before. However, the specificity of the exam guidelines helps to remove at least some of the uncertainty from the coding process. The pocket guide should help you to code with greater confidence that the documentation in your notes justifies the level of service.

3. The quick-reference list

The third tool we developed is really an abbreviated version of the pocket guide, designed simply to help familiarize you with the revised guidelines for multisystem exams. You'll want to duplicate it, preferably on card stock, to make it easier to handle. The quick-reference list reproduces from the pocket guide the exam table and the list of clinical elements that comprise the general multisystem exam, providing you with an easy way to consult the guidelines as you write or dictate your note.

Quick-Reference List:The General Multisystem Exam

Content and Documentation Requirements

Systems/AreasBulleted elements


  • Any three vital signs

  • General appearance of patient


  • INSP of conjunctivae & lids

  • EX of pupils & irises

  • Ophthalmoscopic EX of optic discs & posterior segments

Ears, Nose, Mouth & Throat

  • External INSP of ears & nose

  • Otoscopic EX of external auditory canals & tympanic membranes

  • ASSMT of hearing

  • INSP of nasal mucosa, septum & turbinates

  • INSP of lips, teeth & gums

  • EX of oropharynx: oral mucosa, salivary glands, hard & soft palates, tongue, tonsils & posterior pharynx


  • EX of neck

  • EX of thyroid


  • ASSMT of respiratory effort

  • Percussion of chest

  • PALP of chest

  • Auscultation of lungs


  • PALP of heart

  • Auscultation of heart with notation of abnormal sounds & murmurs

EX of:

  • carotid arteries

  • abdominal aorta

  • femoral arteries

  • pedal pulses

  • extremeties for edema &/or varicosities

Chest (Breasts)

  • INSP of breasts

  • PALP of breasts & axillae

Gastrointestinal (Abdomen)

  • EX of abdomen with notation of presence of masses or tenderness

  • EX of liver & spleen

  • EX for presence or absence of hernia

  • EX of anus, perineum & rectum, including sphincter tone, presence of hemorrhoids, rectal masses

  • Obtain stool sample for occult blood test when indicated



  • EX of the scrotal contents

  • EX of the penis

  • Digital rectal EX of prostate gland


Pelvic EX, including:

  • External genitalia & vagina

  • Urethra (masses, tenderness, scarring)

  • Bladder

  • Cervix

  • Uterus

  • Adnexa/parametria


PALP of lymph nodes in two or more areas:

  • Neck

  • Axillae

  • Groin

  • Other


  • EX of gait & station

  • INSP &/or PALP of digits & nails

EX of joint(s), bone(s) & muscle(s) of one or more of the following six areas: 1) head & neck; 2) spine, ribs & pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; & 6) left lower extremity. The EX of a given area includes:

  • INSP &/or PALP with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions

  • ASSMT of range of motion with notation of any pain, crepitation or contracture

  • ASSMT of stability with notation of any dislocation, subluxation or laxity

  • ASSMT of muscle strength & tone with notation of any atrophy or abnormal movements


  • INSP of skin & subcutaneous tissue

  • PALP of skin & subcutaneous tissue


  • Test cranial nerves with notation of any deficits

  • EX of deep tendon reflexes with notation of pathological reflexes

  • EX of sensation


  • Description of patient's judgment & insight

Brief ASSMT of mental status, including:

  • orientation to time, place & person

  • recent & remote memory

  • mood & affect

Good luck

The revised documentation guidelines, albeit anxiety provoking, can be a useful tool for evaluating your documentation. you're thinking, “Why bother?” remember that Medicare will be reviewing E/M claims and may audit your charts. The guidelines can help keep you step ahead of the game. Also keep in mind that Medicare isn't the only entity with a reason to be interested in your documentation habits. Increasingly, managed care organizations are auditing the charts of the physicians they contract with to ensure that the documentation provides evidence of the physicians' performance quality.

Finally, consider this: With the guidelines comes the potential for discovering that you're actually underbilling Medicare, in which case the time you invest in learning the guidelines can pay off, literally.

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Copyright © 1998 by the American Academy of Family Physicians.

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