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Problem Focused 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 Problem Focused Exam is the least intensive exam. We recommend using the 1997 physical exam rules.

1997 Problem Focused Exam

One to five bullets from one or more organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: CTA
CV: RRR, no MRGs

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)

Total Bullets = four (although only one to five bullets are required)

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Click to return to E/M University Home page, EM Coding Education