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Skin Examination System/Body Area Constitutional 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 by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) Head and Face Eyes Ears, Nose, Mouth and Throat Neck Inspection of conjunctivae and lids Inspection of teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx) Examination of thyroid (eg, enlargement, tenderness, mass) Respiratory Cardiovascular Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness) Chest (Breasts) Gastrointestinal (Abdomen) Examination of liver and spleen Examination of anus for condyloma and other lesions Genitourinary Lymphatic Palpation of lymph nodes in neck, axillae, groin and/or other location Musculoskeletal Extremities Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes) 41 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 155
System/Body Area Skin Elements of Examination Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas: Head, including the face and Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back Right upper extremity Left upper extremity Right lower extremity Left upper extremity NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements. Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis Neurological/ Psychiatric Brief assessment of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation) Content and Documentation Requirements Level of Exam Problem Focused Expanded Problem Focused Detailed Comprehensive Perform and Document: One to five elements identified by a bullet. At least six elements identified by a bullet. At least twelve elements identified by a bullet. Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border. 42 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 156
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Medicare Physician Guide A Resource
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ICD-9-CM Notice The International C
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MEDICARE PHYSICIAN FEE SCHEDULE ...
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CHAPTER ONE INTRODUCTION TO THE MED
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THE MEDICARE PROGRAM The Medicare P
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worker must have a specified number
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Part B - Medical Insurance Some of
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Where to Find Additional Informatio
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CMS contracts with one Quality Impr
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This chapter discusses Medicare pro
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staff or faculty appointments, part
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The following forms are often requi
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Accept the Medicare allowed amount
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Below is an illustration of the pay
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cultural background, or ability to
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This chapter provides information a
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suppliers can obtain a list of elec
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Insurer information (name, group nu
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Coordination of Benefits Contractor
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In these situations, the physician
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Where to Find Additional Informatio
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OTHER HEALTH INSURANCE PLANS Medica
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Part B Railroad Retirement Benefits
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This chapter discusses Medicare cov
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2) Renal dialysis treatments Renal
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2) Furnished by the physician or au
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Services that are considered not me
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This chapter discusses common sets
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International Classification of Dis
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CHAPTER SIX PROTECTING THE MEDICARE
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codes that describe what is and is
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Consistently using billing or reven
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Investigations A Program Safeguard
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Sanctioned and Reinstated Provider
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CHAPTER SEVEN INQUIRIES, OVERPAYMEN
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If Medicare pays more than the corr
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It contains the name, telephone num
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filed), the time limit will be exte
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Liability and Appeal Decisions Liab
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REFERENCE SECTION Medicare Physicia
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Coinsurance Under the Original Medi
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Medically Necessary Services or sup
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Participating Provider or Supplier
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ACRONYMS AA ABN AEP AIC ALJ ASC CAH
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HIC HIPAA HPSA ICD-9-CM ICD-10-CM/P
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RRB RVU SA SEP SGR SHIP SLP SNF SSA
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Electronic Billing & EDI Transactio
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National Provider Identifier Standa
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United Mine Workers of America Elec
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1995 DOCUMENTATION GUIDELINES FOR E
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II. DOCUMENTATION OF E/M SERVICES T
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DG: The CC, ROS and PFSH may be lis
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Page 123 and 124: REVIEW OF SYSTEMS (ROS) A ROS is an
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Physician

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