1997 Physical Exam Bullets Coding Based on Time

Coding Based on Time 1997 Physical Exam Bullets Genitourinary (Female). *When Coding Based on TIME, you MUST spend the entire Examination of the external genitalia Constitutional allotted time face-to-face with the patient AND over half of Examination of the urethra that time must have been devoted to counseling and/or co- Three vital signs Examination of the bladder (fullness, masses, tenderness). ordination of care. Time spent must be documented. General appearance Examination of the cervix Eyes Examination of the uterus (size, contour, position, mobility). Examination of the adnexa (masses, tenderness, nodularity). Critical Care Services E/M Coding Guide Critical care is the direct delivery by a physician of medical Inspection of conjunctivae and lids Examination of pupils and irises (PERRLA). Lymphatic: Palpation of lymph nodes in two or more care for any critical illness which acutely impairs one or Rational Physician Coding Steps areas: more vital organ systems.

History It only takes ONE item from the above table to qualify for any level of risk. Use highest risk present. Stratify risk based on the presenting problems, diagnostic procedures or management options selected

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