Exam: Single Organ System

Published 01/23/2018

The single organ system examinations recognized by CPT are described in detail in the following table. Variations among these examinations in the organ systems and body areas identified in the left columns and in the elements of the examinations described in the right columns reflect differing emphases among specialties.

To qualify for a given level of single organ system examination, the following content and documentation requirements should be met:

Examination Documentation
Problem Focused Examination Should include performance and documentation of one to five elements identified by a bullet, whether in a box with shaded or unshaded border.
Expanded Problem Focused Examination Should include performance and documentation of at least six elements identified by a bullet, whether in a box with a shaded or unshaded border.
Detailed Examination Examinations other than the eye and psychiatric examinations should include performance and documentation of at least 12 elements identified by a bullet, whether in a box with a shaded or unshaded border.
Eye and Psychiatric Examinations Should include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or unshaded border.
Comprehensive Examination Should include performance of all elements identified by a bullet, whether in a shaded box or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.