What constitutes a complete exam under the 1995 documentation guidelines?

A complete exam under the 1995 documentation guidelines requires an evaluation of all eight organ systems. This standard is defined by the need to perform a comprehensive assessment that covers various aspects of the patient's health. Each organ system reviewed contributes to the overall understanding of the patient's condition and ensures that the necessary information is collected to make informed clinical decisions.

The eight organ systems that should be examined include the cardiovascular, respiratory, gastrointestinal, neurological, musculoskeletal, skin, eyes, ears, nose, and throat systems, among others. By addressing all of these systems, the examination satisfies the requirement for a complete exam as per the specified documentation guidelines.

This level of detail is necessary in certain clinical scenarios, particularly when the patient's presenting problems warrant a thorough assessment or when there is a need to establish a baseline for future care. A complete exam is critical for accurately coding the visit and justifying the level of service provided.