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Exam Bullets


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.



* Three vital signs
* General appearance


* Inspection of conjunctivae and lids
* Examination of pupils and irises (PERRLA)
* Ophthalmoscopic discs and posterior segments

Ears, Nose, Mouth, and Throat

* External appearance of the ears and nose (overall appearance, scars, lesions, masses)
* Otoscopic examination of the external auditory canals and tympanic membranes
* Assessment of hearing
* Inspection of nasal mucosa, septum and turbinates
* Inspection of lips, teeth and gums
* Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx


* Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
* Examination of thyroid


* 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)
* Auscultation of the lungs


* Palpation of the heart (location, size, thrills)
* Auscultation of the heart with notation of abnormal sounds and murmurs
* Assessment of lower extremities for edema and/or varicosities
* Examination of the carotid arteries (e.g., pulse amplitude, bruits)
* Examination of abdominal aorta (e.g., size, bruits)
* Examination of the femoral arteries (e.g., pulse amplitude, bruits)
* Examination of the pedal pulses (e.g., pulse amplitude)

Chest (Breasts)

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

Gastrointestinal (Abdomen)

* Examination of the abdomen with notation of presence of masses or tenderness
* Examination of the liver and spleen
* Examination for the presence or absence of hernias
* Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
* Obtain stool for occult blood testing when indicated

Genitourinary (Male)

* Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)
* Examination of the penis
* Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness)

Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures, which may include:

* Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)
* Examination of the urethra (e.g., masses, tenderness, scarring)
* Examination of the bladder (e.g., fullness, masses, tenderness)
* Examination of the cervix (e.g., general appearance, discharge, lesions)
* Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
* Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)


Palpation of lymph nodes two or more areas:

* Neck
* Axillae
* Groin
* Other


* Examination of gait and station
* Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

Examination of the joints, bones, and muscles of one or more of the following six areas:

1. head and neck
2. spine, ribs, and pelvis
3. right upper extremity
4. left upper extremity
5. right lower extremity
6. left lower extremity

The examination of a given area may include:

# Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
# Assessment of range of motion with notation of any pain, crepitation or contracture
# Assessment of stability with notation of any dislocation, subluxation, or laxity
# Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any atrophy or abnormal movements


* Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
* Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)


* Test cranial nerves with notation of any deficits
* Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)
* Examination of sensation (e.g., by touch, pin, vibration, proprioception)


* Description of patient’s judgment and insight

Brief assessment of mental status which may include

* orientation to time, place, and person
* recent and remote memory
* mood and affect

E/M University Coding Tip: the 1995 physical exam rules may seem appealing, but they are too vague and subjective to be relied upon to withstand a systematic audit. It is recommended that physicians utilize the more concrete 1997 physical exam rules (see above)


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