What does a 'Comprehensive' level exam require in terms of documentation?

A 'Comprehensive' level exam requires documentation from performing all elements from 9 organ systems. This means that the physician must document a thorough examination that covers the entire spectrum of the patient’s anatomy and physiology.

In terms of clinical coding and documentation standards, this level of examination reflects a complete approach to patient care, ensuring that no aspect of potential health concerns is overlooked. By evaluating and documenting findings from all organ systems, this level of exam provides a comprehensive understanding of the patient's overall health status.

This high level of examination is essential for accurately coding and billing in accordance with the requirements for a comprehensive visit. It also plays a crucial role in clinical decision-making, ensuring that healthcare providers have a robust foundation of information to address any existing or emerging health issues.