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Exam component of MDM


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I often have trouble determining whether what the provider has covered in the exam may be counted when I'm trying to figure out the level of medical decision-making. I have several providers who document the same systems/body areas, very often with same wording, for most any type of visit. The guidelines state we can count the "affected "area and "symptomatic" or "related "areas. Is it up to ME to decide what can be counted, or do I go by what the provider has documented, assuming he/she will only cover what he/she feels is pertinent?

For example: Pt in for followup of hepatitis B carrier status. No symptoms. Exam then covers Constitutional (no distress), Respiratory (clear), CV (RRR, S1/S2), Abdomen (soft, nontender, no RUQ pain), Extremities (moving all 4), Neuro (no obvious weakness), and Psych (calm, coherent, denies SI).

What areas/systems am I allowed to count or do I count them all since provider covered them all? How/why are Extremities important/related to the presenting problem?

Same provider does SAME exam as above for pt in for shoulder pain, though he does additionally document tenderness with ROM when lifting arm above head. But how/why is Abdomen related to the presenting problem of shoulder pain?

Another provider sees a pt for followup of GERD. The exam includes HEENT (TM, nose, throat clear). Is that related to GERD? Neck, Neuro, and Skin are also covered in the exam. Do I count it all since the provider documented it?

Another: Pt in for followup of Dilantin level. Lab result reviewed and provider refills medication. It's a short SOAP note except for the exam portion, which very briefly covered 7 body systems...count them all?

I would appreciate any advice on this. I have searched this forum, gone through the guidelines, researched other sources, and just looked everywhere (or so it feels) and I have yet to see this question addressed. How do we as coders determine what part of the exam is counted, or do we just count it all?

Thank you!


Phoenix, Arizona
Best answers
I would always go by what the provider documents. Keep in mind that in the PE, the provider might be ruling things out, not necessarily doing it to cover the signs/symptoms the patient is currently experiencing. (unless of course it's a lower level chart)

With the examples you gave, I would count them exactly as you listed. Again, a PE doesn't necessarily go off of what the patient is currently experiencing, it could be going off of things to rule out and eliminate.

Hope that helps!