# Exam:  WHAT DO YOU THINK?



## Lassal423 (Jul 17, 2012)

I am so curious what others would say about the Exam level for this documentation (using 1995 guidelines).  Established patient seen for f/u of kidney stones - EPF, DETAILED or COMPREHENSIVE exam??

Constitutional:  General appearance:   well-developed. Level of distress: NAD
Head:  normocephalic and atraumatic
Eyes: Lids and conjunctivae:  Non-injected, Sclerae: non-icteric
ENMT: Ears: external ears normal, Nose: external nose normal, Oropharynx: moist mucous membranes
Neck:  Supple and no masses
Lungs: Respiratory effort: no dyspnea. Auscultation: CTA bilateral air movement present
Cardiovascular: Heart auscultation: normal S1 and S2, no rubs or murmurs
Abdomen: Bowell sounds: normal, soft, non-distended and no tenderness
Musculoskeletal:  Extremities: no cyanosis or edema
Skin:  warm and dry
Psychiatric:  good judgement. Mental Status: normal mood and affect

I'll share what I came up with & why, after I get some other opinions.

Thank you!
Lora


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## MnTwins29 (Jul 18, 2012)

*Not comprehensive*

Since it mentions body parts such as the neck, and I only count 7 systems, I won't classify as comprehensive.   I am even hesitant on detailed, since there isn't a great amount of detail in any one area and since this is a F/U on Kidney stones, I would look for some more detail in at least the GU system.   If am a "hard A**" on this, I would have to go EPF. 

My $0.02


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## Lassal423 (Jul 18, 2012)

Thank you Lance!  I agree with you.  I believe these docs were given the instruction that 'as long as there are 8 systems documented, it's Comprehensive'. (I think that person was confusing the 95 & 97 guidelines)

I love this forum...how else could I get the opinions of others in our field??

Thanks again!
Lora


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## FTessaBartels (Jul 26, 2012)

*Comprehensive using 1995*

You DO have 8 or more systems documented ... so for 1995 guidelines you have a comprehensive exam:
Constitutional
Eyes
ENT
Respiratory
Cardiovascular
GI (even though he titles it "abdomen" this is an exam of the GI system)
Musculoskeletal
Skin
Psychiatric

Now, whether this should count to give the higher level of service is another question.  Especially since there is NO exam for the problem (i.e. renal/GU).

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Lassal423 (Jul 31, 2012)

Tessa - That is the BIG question, isn't it?  ...do you give credit for a Comprehensive exam just because their template is set up for 8 organ systems...

I wish this was more clearly defined!


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## sullivak (Aug 2, 2012)

My 2 cents worth - 8 systems(Comprehensive exam technically).  I am more accustomed to 97 guidelines, but this is how I would count it for 95.  Tessa makes a great point - the patient is seen for kidney stones - and no related exam?  I agree with Lora's statement, and am constantly troubled by all of the template-generated exams I've been seeing lately.  Medical necessity is supposed to be driving these exams, but with the templates, all that has really changed.

1 - Constitutional: General appearance: well-developed. Level of distress: NAD
- Head: normocephalic and atraumatic [wouldn't count - too vague a statement]
2 - Eyes: Lids and conjunctivae: Non-injected, Sclerae: non-icteric
3 - ENMT: Ears: external ears normal, Nose: external nose normal, Oropharynx: moist mucous membranes
- Neck: Supple and no masses [body area]
4 - Lungs: Respiratory effort: no dyspnea. Auscultation: CTA bilateral air movement present
5 - Cardiovascular: Heart auscultation: normal S1 and S2, no rubs or murmurs
6 - Abdomen: Bowell sounds: normal, soft, non-distended and no tenderness
- Musculoskeletal: Extremities: no cyanosis or edema [I would count this as a CV element, not M/S]
7 - Skin: warm and dry
8 - Psychiatric: good judgement. Mental Status: normal mood and affect


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