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Physical Exam


Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.

The Comprehensive Physical Exam is the highest level of physical exam. We recommend using the 1997 physical exam rules.

At least two bullets from each of nine organ systems


Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA
HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules
Psych: Appropriate affect, alert and oriented to person, place and time

Systems and Bullets

(1 bullet for three vital signs)
(1 bullet for general appearance)

(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)

Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose—“atraumautic”)
(1 bullet for examination of oropharynx)

(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)

(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)

(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)

(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)

(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)

(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)

(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)

Total systems = 10 (although only nine are required)
Total bullets = 20 (although only 18 are required—two in EACH of nine systems)

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