EMRs and the Physical Exam

By Steve Adams

With an increasing number of providers continuing the transition to electronic medical records (EMR), it is important to review one component of evaluation and management (E/M) coding that is often overlooked when creating your EMR templates.

The federal government, in conjunction with the American Medical Association (AMA) has developed two sets of physical exam guidelines that providers must adhere to when documenting and selecting any set of E/M codes.

Whether you select to document with the “1995” exam guidelines, or “1997 – bullet” exam guidelines is up to you.  However, most providers are unaware of the difference in these two guidelines and if you don’t specify which set you want to use with your EMR, you are setting yourself up for disaster if ever audited.

Let’s now take a look at the two sets of guidelines so you will be able to make a decision on which one of the two sets of guidelines you want to use to help ensure documentation compliance.

1995 Guidelines:  This is a set of body areas and organ systems that when used in conjunction with each other allows you to document and select any number of E/M codes.  The only compliance issue that we see with the 1995 exam happens when a provider selects E/M services that require a “comprehensive 8-organ system exam.”  The AMA and CMS specify that a comprehensive exam be made up of only organ systems and not a combination of organ systems and body areas.  The following are the ONLY recognized organ systems from CMS and the AMA.  If you document a comprehensive exam and any of your headings are different from these key organ systems, you’d need to contact your EMR provider and change the headings:

The 12 organ systems: Constitutional, Eyes, ENMT, Lymphatic, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Neurological, Psychiatric, Skin

Now, once you get the headings correct, you can document whatever findings you want regarding the system(s) being examined.  In fact, CMS writes that a notation of “normal” is acceptable.

1997 Guidelines were then developed as an option for providers not wanting to document exams of organ systems, but to be able to document findings from a combination of systems and areas. However, the federal government is very specific about the areas and systems you examine AND what you are able to document regarding your findings within those systems and areas.  In other words, it’s not sufficient to select an exam of the Abdomen, under the 1997 guidelines, and document whatever you want regarding your exam findings.  Specifically, for an abdominal exam the government will give you “credit” if you document your exam and findings pertaining to the any of the following five elements:


  • Examination of abdomen with notation of presence of masses or tenderness
  • Examination of liver and spleen
  • Examination for presence or absence of hernia
  • Examination of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
  • Obtain stool sample for occult blood test when indicated

Different E/M codes require a different number of “elements” be documented for each E/M code.

For an example Multi-System Examination Color Code-it Form, click HERE.

If you believe you are set up to document the 1997 guidelines, but you weren’t informed of the only findings you could document for proper “credit,” you’re documentation might not be as compliant as you think.

The point is, unless you are familiar with the specific set of examination guidelines you are using (1995 vs. 1997), the use of an EMR for documentation compliance could be a fruitless endeavor.

What to do?

  1. Contact your EMR vendor to ensure they are familiar with the difference in the 1995 and 1997 guidelines as they pertain to the physical examination.
  2. Ask them to let you know which system you are currently using for your template.
  3. Do some research on your own.  The following is a link to the CMS Documentation Guidelines for Evaluation and Management Services: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
  4. Consider having an outside review of some of your new and established patient notes to ensure you have had your templates set up appropriately.  Normally after a review of 5 new and 5 established physical examinations an auditor can offer you suggestions on your documentation compliance.

Please don’t overlook this very important component of your EMR documentation compliance.

Steve Adams is a Certified Professional Coder and Senior Consultant with InGauge Healthcare Solutions.  Contact Steve for consulting or educational programs at steve.adams@inguagehsi.com.  To read more articles like this and to register for practice management tele-classes, visit www.efficiencyinpractice.com

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