# 95 Exam Requirements



## LindaEV (Nov 18, 2009)

Does anyone have any clarification on what a detailed exam is? What exactly does  "an extended examination of the affected body area(s) and other symptomatic or related organ system(s)." mean? 

Thanks!


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## FTessaBartels (Nov 18, 2009)

*1995 guidelines vague*

The 1995 guidelines are vague, and have never been clearly defined. Which is why they came out with the 1997 guidelines.

Thre are two schools of thought on what makes a detailed exam under 1995 guidelines. 

Option 1:  5-7 body areas/systems  It is easy to count these systems, but does that mean an "extended exam of the affected area"?  I would argue it does *not*. 

Option 2: an extended exam of the affected body area or system, plus other related systems.  But what does this mean?

Nobody really knows.  But if the chief complaint is sinus congestion and the exam is only "Nares patent" I'd argue this was NOT an extended exam.  

On the other hand if your exam included "Sclera clear,  lids inflamed and red, oral mucosa moist, thick nasal secretions, facial swelling and tenderness"  I would argue this is an extended exam of the affected area. Then all you would need is other related systems (e.g. lungs clear to auscultation, Temp 99.3) and you'd have your detailed exam. 

Hope this helps.

F Tessa Bartels, CPC, CEMC


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## LindaEV (Nov 19, 2009)

Tessa, thank you, this does help....I just don't do well with "vague"...and either do my docs....they want to-the-letter, in writing guidelines.


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