General Multi Exam PE as per Medicare

General & Administrative
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Constitutional
Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)[textarea name="field_name" default="sample text"]
Eyes
Inspection of conjunctivae and lids
Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry)
Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
[textarea name="field_name" default="sample text"]
Ears, Nose, Mouth Throat
External inspection of ears and nose (eg, overall appearance, scars, lesions, masses)
Otoscopic examination of external auditory canals and tympanic membranes Assessment of hearing (eg, whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum and turbinates
Inspection of lips, teeth and gums
Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx
[textarea name="field_name" default="sample text"]
Neck
Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)
Examination of thyroid (eg, enlargement, tenderness, mass)
[textarea name="field_name" default="sample text"]
Respiratory
Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus)
Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
[textarea name="field_name" default="sample text"]
Cardiovascular
Palpation of heart (eg, location, size, thrills)
Auscultation of heart with notation of abnormal sounds and murmurs Examination of:
carotid arteries (eg, pulse amplitude, bruits) abdominal aorta (eg, size, bruits)
femoral arteries (eg, pulse amplitude, bruits) pedal pulses (eg, pulse amplitude) extremities for edema and/or varicosities
[textarea name="field_name" default="sample text"]
Chest/Breast
Inspection of breasts (eg, symmetry, nipple discharge)
Palpation of breasts and axillae (eg, masses or lumps, tenderness)
Gastrointestinal
Examination of abdomen with notation of presence of masses or tenderness
Examination of liver and spleen
Examination for presence or absence of hernia
Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
Obtain stool sample for occult blood test when indicated [textarea name="field_name" default="sample text"]
Genitourinary
MALE:
Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
Examination of the penis
Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)
FEMALE:
Pelvic examination (with or without specimen collection for smears and cultures), including
Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
Examination of urethra (eg, masses, tenderness, scarring) Examination of bladder (eg, fullness, masses, tenderness)
Cervix (eg, general appearance, lesions, discharge)
Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)[textarea name="field_name" default="sample text"]
Lymphatic
Palpation of lymph nodes in two or more areas: Neck
Axillae Groin Other
[textarea name="field_name" default="sample text"]
Musculoskeletal
Examination of gait and station
Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:
Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of any pain, crepitation or contracture
Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
[textarea name="field_name" default="sample text"]
Skin
Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)
[textarea name="field_name" default="sample text"]
Neurologic
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
Examination of sensation (eg, by touch, pin, vibration, proprioception)
[textarea name="field_name" default="sample text"]
Psychiatric
Description of patient’s judgment and insight Brief assessment of mental status including:
orientation to time, place and person
recent and remote memory
mood and affect (eg, depression, anxiety, agitation)
[textarea name="field_name" default="sample text"]
Constitutional
Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Eyes
Inspection of conjunctivae and lids
Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry)
Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

Ears, Nose, Mouth Throat
External inspection of ears and nose (eg, overall appearance, scars, lesions, masses)
Otoscopic examination of external auditory canals and tympanic membranes Assessment of hearing (eg, whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum and turbinates
Inspection of lips, teeth and gums
Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

Neck
Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)
Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory
Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus)
Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular
Palpation of heart (eg, location, size, thrills)
Auscultation of heart with notation of abnormal sounds and murmurs Examination of:
carotid arteries (eg, pulse amplitude, bruits) abdominal aorta (eg, size, bruits)
femoral arteries (eg, pulse amplitude, bruits) pedal pulses (eg, pulse amplitude) extremities for edema and/or varicosities

Chest/Breast
Inspection of breasts (eg, symmetry, nipple discharge)
Palpation of breasts and axillae (eg, masses or lumps, tenderness)
Gastrointestinal
Examination of abdomen with notation of presence of masses or tenderness
Examination of liver and spleen
Examination for presence or absence of hernia
Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
Obtain stool sample for occult blood test when indicated
Genitourinary
MALE:
Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
Examination of the penis
Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)
FEMALE:
Pelvic examination (with or without specimen collection for smears and cultures), including
Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
Examination of urethra (eg, masses, tenderness, scarring) Examination of bladder (eg, fullness, masses, tenderness)
Cervix (eg, general appearance, lesions, discharge)
Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
Lymphatic
Palpation of lymph nodes in two or more areas: Neck
Axillae Groin Other

Musculoskeletal
Examination of gait and station
Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:
Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of any pain, crepitation or contracture
Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Skin
Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)

Neurologic
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
Examination of sensation (eg, by touch, pin, vibration, proprioception)

Psychiatric
Description of patient’s judgment and insight Brief assessment of mental status including:
orientation to time, place and person
recent and remote memory
mood and affect (eg, depression, anxiety, agitation)
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    bryanuop
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    Constitutional Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse
    [See the full post at: General Multi Exam PE as per Medicare]

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