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Detailed 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 Detailed Physical Exam is the second highest level of physical exam. We recommend using the 1997 physical exam rules.

1997 Detailed Exam requires at least 12 bullets from any organ systems.

At least 12 bullets from any organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)

Total bullets = 12





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