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Organ Systems
 

 



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 1997 E/M guidelines recognize the following organ systems:

  • Constitutional
  • Eyes
  • Ears, nose, mouth and throat
  • Neck
  • Respiratory
  • Cardiovascular
  • Chest (breasts)
  • Gastrointestinal (abdomen)
  • Genitourinary (male)
  • Genitourinary (female)
  • Lymphatic
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric

1995 E/M guidelines recognize the following body areas and organ systems:

Body Areas

  • Head, including the face
  • Neck
  • Chest, including breasts and axillae
  • Abdomen
  • Genitalia, groin, buttocks
  • Back, including spine
  • Each extremity

Organ Systems

  • Constitutional (e.g., vital signs, general appearance)
  • Eyes
  • Ears, nose, mouth and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic

Using the 1995 E/M guidelines, the various levels of physical exam are defined as follows:

Problem Focused - a limited examination of the affected body are or organ system

Expanded Problem Focused - a limited examination of the affected body area or organ system and other symptomatic or related organ systems

Detailed - an extended examination of the affected body area(s) and other symptomatic or related organ system(s)

Comprehensive - a general multi-system examination or complete examination of a single organ system

 

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