Answer to Question 1
Challenges include (but are not limited to)
The general multisystem physical examination guidelines were written by physicians for physicians, so the language of the guidelines can be difficult to understand
Any nonclinically trained person who is reviewing the general multisystem physical examination guidelines may find the clinical language intimidating or too difficult to understand.
Fully understanding the general multisystem physical examination guidelines can require additional research and self-education about anatomy and pathology
Not all physicians document the physical examination with the amount of specificity required by the general multisystem physical examination guidelines, so these guidelines may not be helpful for certain E/M documentation
Answer to Question 2
Benefits include (but are not limited to):
Greater anatomic specificity
Increased likelihood of identifying specific abnormal findings
More thorough documentation of the physical examination, which can lead to improved coordination of care in future E/M visits
Clearer identification of what was examined during the physical examination, especially the specific elements of the organ system or body area
Definitive correlation between the documented findings of the physical examination and the nature of the presenting problem.
Reviewing the general multisystem physical examination guidelines can greatly improve understanding of the physical examination that was actually performed by the physician
The general multisystem physical examination guidelines are a very useful reference tool for medical coders, regardless of the field in which the medical coder works, because of the anatomic specificity of the guidelines
The general multisystem physical examination guidelines are a valuable reference when learning about human anatomy and pathology
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