What differentiates an expanded problem focused exam from a detailed exam according to 1995 documentation guidelines?

The distinction between an expanded problem focused exam and a detailed exam, according to the 1995 documentation guidelines, primarily lies in the amount of information documented. An expanded problem focused exam involves reviewing a limited number of items in the patient’s history and performing a focused examination, while a detailed exam requires a more comprehensive review of systems and a more thorough physical examination.

In the context of coding and documentation, the amount of medical information that is gathered and recorded during the exam influences the coding level. For example, a detailed exam typically encompasses additional elements, such as an extensive review of systems and a more comprehensive evaluation of the physical findings when compared to an expanded problem focused exam. This increased level of documentation is what enables coders to differentiate between the two types of examinations when assigning codes for services rendered.

The other options touch upon aspects of the examination process but do not fundamentally address the differentiation as outlined in the documentation guidelines. For instance, while the types of tests ordered might vary between each exam type, it is the scope of history and examination documented that primarily defines the differentiation. Similarly, location could refer to where the exam is conducted and duration may pertain to time spent, but these factors do not explicitly categorize the exams per the guidelines. Therefore, the