# Detailed exam, 1995 exam



## JesseL (Apr 9, 2015)

Does below meet 1995 detailed exam guidelines "2-7 extended exam of areas or systems"

I was told if there's atleast 3 or more bullets in two or more systems and/or areas, its considered extended exam.

c/o heaviness of the head and dizziness 

General Examination: 

GENERAL APPEARANCE: in no acute distress, well developed, well nourished. (extended?)
EYES: pupils equal, round, reactive to light and accommodation. (extended?)
NECK:  supple, no JVD. (limited?)
HEART: no murmurs, regular rate and rhythm, S1, S2 normal.  (extended?)
LUNGS: clear to auscultation bilaterally. (limited)
EXTREMITIES: no clubbing, cyanosis, or edema. (extended?)
NEUROLOGIC: nonfocal, motor strength normal upper and lower extremities, sensory exam intact.(extended?)

Would this also meet "detailed" per 1997 exam guidelines? 2 bullets from any 6 areas and systems...


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## twizzle (Apr 9, 2015)

JesseL said:


> Does below meet 1995 detailed exam guidelines "2-7 extended exam of areas or systems"
> 
> I was told if there's atleast 3 or more bullets in two or more systems and/or areas, its considered extended exam.
> 
> ...


With regards to 1995 guidelines (which doesn't have anything to do with bullets) this is a detailed exam(5-7 body areas or organ systems).
Don't have my 1997 DG with me so not sure if it meets the 12 bullet requirement for detailed. I do know that the 12 bullets don't have to be from any specified number of areas/systems. That only applies to a comprehensive multi-system exam which is at least 2 bullets from any 9 organ systems.


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## JesseL (Apr 9, 2015)

twizzle said:


> With regards to 1995 guidelines (which doesn't have anything to do with bullets) this is a detailed exam(5-7 body areas or organ systems).
> Don't have my 1997 DG with me so not sure if it meets the 12 bullet requirement for detailed. I do know that the 12 bullets don't have to be from any specified number of areas/systems. That only applies to a comprehensive multi-system exam which is at least 2 bullets from any 9 organ systems.



Per NGS we're suppose to use  EXTENDED exam  2-7 system and/or body areas
http://www.ngsmedicare.com/ngs/wcm/...M_Documentation_Training_Tool.pdf?MOD=AJPERES

I'm not sure if we're allowed to use the 5-7 rule?


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## sathyaraj (Apr 13, 2015)

Hi,

Yes you are in correct way, if you have three elements in any one of the body systems or body area you can consider as extended exam which is applicable other than constitutional.

Regards,
Sathyaraj CPC,CEMC


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## mitchellde (Apr 13, 2015)

The guidelines state:
Detailed – an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
So to just check off the areas of 3-5 systems does not mean it is related to the affected area or that it is symptomatic.  I think we need to be really careful due to template style documentation so that visits do not become over coded.
From what you have provided I do not feel it meets the stated criteria for detailed.


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## JesseL (Apr 13, 2015)

mitchellde said:


> The guidelines state:
> Detailed ? an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
> So to just check off the areas of 3-5 systems does not mean it is related to the affected area or that it is symptomatic.  I think we need to be really careful due to template style documentation so that visits do not become over coded.
> From what you have provided I do not feel it meets the stated criteria for detailed.



Hi Debra,

Can you elaborate more on what you mean by this?  Do you mean you don't feel that the areas examined relate to the chief complaint?


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## mitchellde (Apr 13, 2015)

JesseL said:


> Hi Debra,
> 
> Can you elaborate more on what you mean by this?  Do you mean you don't feel that the areas examined relate to the chief complaint?



The provider needs to document how it relates to the presenting issue.  It is not the job of the coder to decide of they relate or not.  I don't see any kind of detailed exam at all and no reason to believe that the review of the stated systems was related or not.  It really does not look like much if anything was reviewed.  Templet style documentation is too limiting and instead of giving higher levels of care I think it does just the opposite.


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## foot (Apr 14, 2015)

*Ros*

I too have a question regarding this forum.  Our providers would like the patients to complete a ROS form when they present to the office.  My question is this, if the provider is NOT actually performing the review how can this be used to code the e/m level?


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## mitchellde (Apr 14, 2015)

It is acceptable for the patient to fill this out however the provider must document that it was reviewed with the patient and must document the positives and pertinent negatives.  Just having the patient fill it out does not count nor foes it count if the provider documents " see ROS"


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