US · guidance
CMS SOM App. J, Tag W334
§483.460(c)(3)(i) Be by a direct physical examination;
Guidance §483.460(c)(3)(i)
A direct physical examination means a visual review of the body as well as
examination/assessment of body systems. This includes observations made through non-verbal
communication (including visual, tactile, nonverbal gestures, grimaces, etc.) which may be an
indication that there is a potential for further assessment and/or monitoring. A paper review of
the client’s medical record and health statistics does not meet the intent of the regulation for a
direct physical examination.
History
Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
ad3f280c576b30c9587245594d2853571ca2a9a481e84769860fb3e897488942
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