I've seen various guidelines. Some allow 2-7 for detailed--others allow 2-7 with more detail---others only allow 5-7 for detail. I often refer to Palmetto for information and found this.
Jurisdiction 1 Part B
General: 1995 vs 1997 Guidelines
You may follow either the 1995 or 1997 guidelines in determining the appropriate level of service. In comparing the guidelines, changes to 1997 are as follows:
History - In 1997, an extended HPI includes the status of at least three chronic or inactive conditions. This is the only change.
Examination - In 1995, only the multi-system examination was defined. In 1997, the documentation requirements for the multi-system exam have changed (see chart below) and ten single organ system examinations have been developed.
Decision Making - No changes
General Multi-System Examination Type of Examination
95=Detailed Two to seven systems (more detail)
97=At least two bullets from each of the six areas or at least 12 bullets in two or more areas
1995 - For purposes of examination, the following body areas are recognized:
Head, including the face
Chest, including breasts and axillae
Genitalia, groin, buttocks
Back, including spine
1995 and 1997 - For purposes of examination, the following organ systems are recognized:
Constitutional (e.g., vital signs, general appearance)
Ears, nose, mouth and throat
last updated on 03/23/2009
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