What is the range of body areas and/or organ systems for an Expanded Problem Focused exam according to the 1995 DGs?

An Expanded Problem Focused exam, as defined by the 1995 Documentation Guidelines for Evaluation and Management Services (DGs), involves examining a limited number of body areas or organ systems within a patient encounter. The correct range for an Expanded Problem Focused exam is 2 to 7 body areas and/or organ systems.

This classification highlights that the exam is more comprehensive than a problem-focused exam, which only assesses a single area or system, yet not as extensive as a detailed exam that typically covers 8 or more systems. By encompassing 2 to 7 systems, the Expanded Problem Focused exam allows for a more thorough evaluation of the patient’s condition while still focusing on specific issues rather than a comprehensive assessment of all systems.

Understanding this range is essential for appropriate coding and documentation of encounters based on the 1995 DGs, ensuring that healthcare providers are compensated accurately for the level of service provided.