As with the history component requirements, there are differences between Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services (CMS) documentation guidelines for the physical examination. In summary, CPT guidelines are vague; the 1995 CMS guidelines are somewhat more specific; and the 1997 CMS guidelines are much more complex (Table).
Tip:The examination requirements under the 1997 guidelines may differ when performing specialty examinations.
Most payers follow the CMS guidelines and physicians will always be compliant with coding guidelines if 1995 or 1997 CMS guidelines are followed. Once again, the nature of the presenting problem(s) and the medical necessity should determine the level of physical examination performed, documented, and used in code selection. The medical record must clearly reflect the area or systems that are examined.