The general multisystem examination under the Centers for Medicare & Medicaid Services (CMS) 1997 Documentation and Management Guidelines for Evaluation and Management (E/M) Services does not include an element for examination of the fontanelle. If a practice uses the 1997 guidelines to determine the level of physical examination performed, can it create and count bullets for specific examination components that are not included?

Yes, it is appropriate for a physician to count elements such as examination of the fontanelle or other areas of an examination that are not specifically cited as an examination element in the guidelines. Remember, the CMS documentation and management guidelines were based on the adult population because few children are covered under Medicare (one exception being children with end-stage renal disease). Note the following in the 1997 guidelines, under Documentation of E/M Services, paragraph 5:

“These Documentation Guidelines for E/M services reflect the needs of...

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