Exam Guidelines

The Hospitalist. 2011 November;2011(11):

November 1, 2011 | The Hospitalist

Carol Pohlig

Table 2A: 1995 Documentation Guidelines2

Table 2B: 1997 Documentation Guidelines2

Ears, Nose, Mouth, and Throat

External inspection of ears and nose (e.g. overall appearance, scars, lesions, masses);
Otoscopic examination of external auditory canals and tympanic membranes;
Assessment of hearing (e.g. whispered voice, finger rub, tuning fork);
Inspection of nasal mucosa, septum, and turbinates;
Inspection of lips, teeth, and gums; and
Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus); and
Examination of thyroid (e.g. enlargement, tenderness, mass).

Respiratory

Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement);
Percussion of chest (e.g. dullness, flatness, hyperresonance);
Palpation of chest (e.g. tactile fremitus); and
Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs).

Cardiovascular

Palpation of heart (e.g. location, size, thrills);
Auscultation of heart with notation of abnormal sounds and murmurs; and
Examination of:
- Carotid arteries (e.g. pulse amplitude, bruits);
- Abdominal aorta (e.g. size, bruits);
- Femoral arteries (e.g. pulse amplitude, bruits);
- Pedal pulses (e.g. pulse amplitude); and
- Extremities for edema and/or varicosities.

Chest

Inspection of breasts (e.g. symmetry, nipple discharge); and
Palpation of breasts and axillae (e.g. masses or lumps, tenderness).

Gastrointestinal

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, and rectal masses; and
Obtain stool sample for occult blood test when indicated.

Minimum requirements not met

Upon admission to the hospitalist service, a 64-year-old female presents with uncontrolled diabetes mellitus resulting in hyperglycemia. The hospitalist performs a complete exam, but documentation only reflects an expanded, problem-focused exam (with respect to both the 1995 and 1997 guidelines).

An expanded, problem-focused exam does not satisfy the minimum requirements for initial hospital care (99221) (see Table 1).⁴ While some reviewers could say that this service should not be reported (i.e. not billed), because the minimum requirements were not met, CMS has clarified this in a recent transmittal, allowing the physician to report a subsequent hospital care code (99231-99233) that best corresponds to the provided documentation.⁵ Explicitly stated, “Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.”⁵

Genitourinary (Male)

Examination of the scrotal contents (e.g. hydrocele, spermatocele, tenderness of cord, testicular mass);
Examination of the penis; and
Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).

Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures), including:
- Examination of external genitalia (e.g. general appearance, hair distribution, lesions) and vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);
- Examination of urethra (e.g. masses, tenderness, scarring);
- Examination of bladder (e.g. fullness, masses, tenderness);
- Cervix (e.g. general appearance, lesions, discharge);
- Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support); and
- Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).