# What constitutes a complete physical exam?



## CapeCodYankee (Feb 11, 2015)

I cannot find any documentation regarding what exactly constitutes a complete physical exam?

 I am more concerned with the exam itself in regards to "how" many systems should be documented? Does it matter?

 This becomes complicated when an E&M is being billed as well.

Can anyone tell me if there are a certain amount of systems (10+) required as part of a complete routine physical?


Thanks to all


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## jdibble (Feb 12, 2015)

CapeCodYankee said:


> I cannot find any documentation regarding what exactly constitutes a complete physical exam?
> 
> I am more concerned with the exam itself in regards to "how" many systems should be documented? Does it matter?
> 
> ...



There is no specific or "required" number of systems for a preventative physical. The requirements are that the physciain perform an age appropriate history and exam.  Basically it depends on the type of well visit and who they are seeing (child, adult, well woman visit).  For example if a woman is being seen for a well woman exam, the physician should be doing a complete breast and pelvic exam.  Medicare requires for a well woman exam that the doctor documents at least 7 of the 11 pelvic elements as well as the breasts. 

As far as billing an E/M visit at the same time - yes it is very complicated and can be an issue as far as coming up with enough elements for the E/M exam that do not pertain to the well visit.  We usually discourage our physicians from doing this and suggest they have the patient come back either for the problem visit or the well visit, depending on what needs to be addressed at that visit.


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## teresabug (Feb 12, 2015)

for preventives, the requirements are a comprehensive ROS, comp PFSH, and a thorough assessment of risk factors based on the patients age and gender. 

In a perfect world, yes, providers should have patients come back for a separate encounter if they have a complaint outside of what is covered in  a preventive exam. They usually don't, then complain when they only get paid for the preventive and not the E/M as well. Only they can control this. a coder of biller cannot.


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