# What level of physical exam is this?



## Jinx75 (Sep 9, 2016)

Here is the documentation from my provider's office note, please tell me using both 95 and 97 guidelines what level physical exam you get (PF, EXPF, DTLD or Comp)

General examination:
            General appearance:well developed, well nourished, in no acute distress.
            Head:normocephalic, atraumatic
            Neck: no cervical lymphadenopathy, carotid pulse normal, no thyroid nodules, no thyromegaly.
            Lungs: normal volumes
            Abdomen:nondistended
            Skin: warm and dry, no suspicious lesions.
            Vascular: no jugular venous distention, extremities warm and well perfused, no cyanosis, no edema.
Neurological: 
            Mental status:the patient is awake and alert.
            Cranial nervesEERL/EOMI, face symmetric. Tongue midline. Speech fluent.
            Sensory:Sensation is grossly intact to light touch throughout.
            Gait and station:w/in normal limits.
Cervical Spine/Neck:
            C SPINE EXAM:No palpable abnormality, mild paraspinal tenderness, no paravertebral spasm, no percussion
            tenderness. Normal flexion/extension/axial rotation.
Motor Strength:
            Deltoid bilateral 5/5.
            Biceps bilateral  5/5.
            Triceps bilateral 5/5.
            Wrist extensor bilateral 5/5.
            Grip bilateral 5/5.
            Interossii bilateral 5/5.
            Opponens pollicis bilateral 5/5.
            Finger extention bilateral 5/5.
Reflexes:
             Biceps bilateral  2+
             Triceps bilateral 2+
             Radial bilateral 2+
             Hoffman's Absent
             Tone Normal


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## Orthocoderpgu (Sep 9, 2016)

95 body areas 4  EPF
95 Systems    7   Detailed

97  15 bullets in 8 systems   Detailed

In order to get a Comprehensive Exam under 97 you need at least two bullets in at least 9 systems, which you do not have.

Keep in mind that this is using a General Multi-system exam. Looking at this I would want to use maybe a Neurologic specialty exam since you may get a higher level with that, but I have not used that for years so I don't recall at the top of my head, but check it out.


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## Jinx75 (Sep 9, 2016)

I see 8 organ systems...

Constitutional-General appearance: well developed, well nourished, in no acute distress.
Respiratory-Normal volumes
GI-Abdomen non-distended
Skin-Warm, dry no suspicious lesions
Cardiovascular-no jugular venous distention
Eyes-PEERL/EOMI
Neuro-Sensory sensation is grossly intact to light touch
Musculoskeletal-Motor strength, reflexes

Am I wrong?


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## Orthocoderpgu (Sep 12, 2016)

No I think your right. I was not counting the eye and should have.


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