What is the key difference between a Problem Focused Examination and an Expanded Problem Focused Examination?

The key difference between a Problem Focused Examination and an Expanded Problem Focused Examination lies in the number of elements that must be documented for each type of examination. In a Problem Focused Examination, the documentation typically includes 1-5 elements, which may encompass a limited review of the patient's history and examination findings focused on a specific issue. On the other hand, an Expanded Problem Focused Examination requires a more comprehensive approach, which includes at least 6 elements from either the history or the examination. This allows for a broader assessment of the patient's condition within the context of the presenting problem.

Understanding this distinction is essential for accurate coding and billing, as it helps ensure that the level of service provided is appropriately matched to the complexity of the patient's condition. Documenting the correct number of elements not only aligns with the guidelines but also supports the medical necessity of the service rendered.