# Exam



## KaylaRieken (Nov 15, 2017)

GENERAL: Alert and pleasant female who appears in no acute distress.
SKIN: No rash or lesions
NEUROLOGIC: Exam is grossly intact.
HEENT: Head is normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
Neck: Supple
RESPIRATORY: Breathing is unlabored.
EXTREMETIES: She moves all extremities without difficulty.


How many organ systems are here for a 95?


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## Chelle-Lynn (Nov 16, 2017)

For organ systems based on 95 guidelines I come up with the following:

Eye = Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
Neuro = Exam is grossly intact
Repira = Breathing is unlabored
Musco = Head is normocephalic, atraumatic.Neck: Supple. She moves all extremities without difficulty
Skin = No rash or lesions
Psych = Alert and pleasant female who appears in no acute distress.

Note, some will see the psych as constitutional...it is one of those either/or....however in the case the total would still be 6 systems.


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## KaylaRieken (Nov 16, 2017)

Thank you. So this would not be enough for a 99204 with the 95 or the 97 guidelines?


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## Chelle-Lynn (Nov 16, 2017)

For the exam section it would level to a 99203


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