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Expanded Problem
Focused Exam |
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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.
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The Expanded Problem Focused Exam is the second lowest level of physical exam. We recommend using the 1997 physical exam rules.
1997 Expanded Problem Focused Exam
At least six bullets from one or more organ systems
Example
Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, nontender
Extremities: No peripheral edema
(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for examination of the abdomen)
(1 bullet for examination of extremities for edema)
Total bullets = six
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