Saturday, October 17, 2009

Auditing Basics: EXAM (aka... touch)

Exam also known as touch

The exam criteria for auditing has 2 different methodologies to choose from. CMS allows us to choose either the 1995 guidelines or the 1997 guidelines to choose from.

Lets explore the 1995 exam guidelines. The 1995 guidelines allow us to recognize either a "body area" or a body "organ system" These are broken down below.

the following body areas are recognized:

• Head, including the face

• Neck

• Chest, including breasts and axillae

• Abdomen

• Genitalia, groin, buttocks

• Back, including spine

• Each extremity

you can choose to utilize body "organ systems" (do not intermix and confuse the two)

the following organ systems are recognized:

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

When utilizing the 95 guidelines for "body systems" or "body areas" to determine the level to be met CMS has outlined the criteria as:

1995 Guidelines = Problem Focused exam is limited to the affected body area or 1 organ system

1995 Guidelines = Expanded Problem Focused exam is to examine the affected body area + other symptomatic or related organ systems for a total of between 2-4 body areas, or organ systems examined

1995 Guidelines = Detailed exam is to examine the affected body area + other symptomatic or related organ systems for a total of between 5-7 body areas, or organ systems examined

1995 Guidelines = Comprehensive exam is to completely examine the affected body area + other symptomatic or related organ systems for a total of 8 or more body areas, or organ systems examined.

Interestingly, the 1995 guidelines published from CMS was a document of aproximately 15 pages, where the 1997 guidelines were closer to 60 pages. So, from that perspective you have more "choices" in the 1997 bullet points, but less confusion with the 1995 exam criterias.

Now.. Let's explore the 1997 examination guidelines or "bullet points" as they are commonly known as. These "bullet's" are encompassed and "bulleted" to make it easier to "count" which areas have been examined. These bullet points have been broken down as a "multi-system" examinination with a comprehensive laundry list of body areas that can be examined, or you can choose to utilize the 1997 "single system" examination bullet points to meet the criteria. The table below outlines the "multi-system" exam bullet points.

1997 Problem Focused = 1-5 elements denoted by a "bullet"

1997 Expanded Problem Focused = 6-11 or more elements denoted by a "bullet"

1997 Detailed = 12-17 elements denoted by a "bullet" OR at least 2 elements identified from six areas/systems

1997 Comprehensive = 18 or more bullets OR all bullets in 9 or more "systems/areas"

**Separate criteria for Single sytem exam - found within the 1997 CMS guidelines (see link)

System/Body Area

Elements of Examination


• Measurement of any three of the following seven

vital signs: 1) sitting or standing blood pressure,

2) supine blood pressure, 3) pulse rate and

regularity, 4) respiration, 5) temperature, 6)

height, 7) weight (may be measured and recorded)

• General appearance of patient e.g. development,

nutrition, body habitus, deformities, attention to



• Inspection of conjunctivae and lids.

• Examination of pupils and irises e.g. reaction to

light and accommodation, size and symmetry.

• Ophthalmoscopic examination of optic discs e.g.

size, C/D ration, appearance and posterior segments

e.g. vessel changes, exudates, hemorrhages.

Ears, nose,

• External inspection of ears and nose e.g. overall

mouth & throat

appearance, scars, lesions, masses.

• Otoscopic examination of external auditory canals

and tympanic membranes.

• Assessment of hearing e.g. whispered voice,

finger rub, tuning fork.

• Inspection of nasal mucosa, septum and turbinate

• 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 e.g. enlargement

tenderness, mass.


• Assessment of respiratory effect e.g. intercostal

retractions, use of accessory muscles,

diaphragmatic movement.

• Percussion of chest e.g. dullness, flatness,


• Palpation of chest e.g. tactile fremitus

• Auscultation of lungs e.g. breath sounds,

adventitious sounds, rubs.


• Palpation of heart e.g. location, size, thrills

• Auscultation of heart with notation of abnormal

sounds and murmurs.

Examination of:

• Carotid arteries e.g. pulse amplitude, bruits.

• Abdominal aorta e.g. size, bruits

• Femoral arteries e.g. pulse amplitude, bruits.

• Pedal pulse e.g. pulse amplitude

• Extremities for edema and/or varicosities


• Inspection of breasts
e.g. symmetry, nipple



• Palpation of breasts and axillae e.g. masses or

lumps, tenderness.


Examination of abdomen with notation of


presence of masses or tenderness.

• Examination of liver and spleen

• Examination of presence or absence of hernia.

• Examination when indicated of anus, perineum

and rectum, including sphincter tone, presence of

hemorrhoids, rectal masses.

• Obtain stool sample for occult blood test when indicated.


• Examination of the scrotal contents e.g.


hydrocele, spermatocele, tenderness of cord.

• Examination of the penis.

• Digital rectal examination of prostate gland e.g.

size, symmetry, nodularity, tenderness.


Pelvic examination (with or without specimen


collection for smears and cultures) including:

• Examination of external genitalia e.g. general

appearance, hair distribution, lesions and vagina

e.g. general appearance, estrogen effect, discharge,

lesions, pelvic support, cystocele, rectocele.

• Examination of the urethra e.g. masses,

tenderness, scarring.

• Examination of the bladder e.g. fullness, masses,


• Cervix e.g. general appearance, lesions, discharge.

• Uterus e.g. size, contour, position, mobility,

tenderness, consistence, descent or support.

• Adnexa/parametria e.g. masses, tenderness,

organomegaly, nodularity.


Palpation of lymph nodes in two or more areas:

• Neck

• Axillae

• Groin

• Other


• Examination of gait and station.

• Inspection and/or palpations of digits and nails

e.g. clubbing, cyanosis, inflammatory conditions,

petechiae, ischemia, infections, nodes.

Examination of 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.

• Inspection and/or palpation with notation of

presence of any misalignment, asymmetry,

crepitation, defects, tenderness, masses.

• Assessment of range of motion with notation of

any pain, crepitation or contracture.

• Assessment of stability with notation of any

dislocation (luxation), subluxation or laxity.

• Assessment of muscle strength and tone e.g.

flaccid, cog wheel, spastic with notation of any

atrophy or abnormal movements.


• Inspection of skin and subcutaneous tissue e.g.

rashes, lesions, ulcers.

• Palpation of skin and subcutaneous tissue e.g.

induration, subcutaneous nodules, tightening.


• Test cranial nerves with notation of any deficits.

• Examination of deep tendon reflexes with notation

of pathological reflexes e.g. Babinski.

• Examination of sensation e.g. by touch, pin,

vibration, proprioception.


• Description of patient's judgment and insight

Brief assessment of mental status including:

• Orientation to time, place and person

• Recent and remote memory

• Mood and affect e.g. depression, anxiety, agitation.

If you’re still confused regarding exam criteria, please e-mail me or contact me, and I’ll do my best to help!

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