# 4X4 Rule for detailed exam



## HOWRU2DAY (Feb 7, 2013)

I am a little confused about 2 systems using the 4x4 rule. If you have 2 things mentioned in the exam concerning the eyes would it be doubled since there is 2 eyes or would it still only count as 2. If using the 4x4 method to determine  if the exam is problem focused or detailed is ENT considered one system, for instance if you have 4 things  mentioned about the throat and also the ears would you be able to count both of them for the 4x4 or would it only be one since ENT is considered one system.


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## Tonyj (Feb 7, 2013)

Assuming you're referring to Novitas Solutions, Inc as your MAC, there is an advanced E/M webinar coming up 2/12/13, 11am - 12:30pm ET. There you can ask questions and get a better understanding of the 4x4 rule.

In answering your question here's an example from a previous webinar.

Constitutional-1)BP 2)temp 3)pulse 4)respiration
Cardiovascular-1) Regular rate 2)and Rhythm 3)Normal S1 4) and S2
Gastrointestinal- 1) abdomen soft 2) normal bowel sounds 3) no hernia 4)abdomen flat

As per the example as long as the physician mentions ear, nose, mouth, throat he has made all 4 requirements in the organ system. Eyes is usually PERRLA (Pupils Equal, Round, Reactive To Light And Accommodation) would be appropiate for 4x4

Hope this helps


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## HOWRU2DAY (Feb 7, 2013)

*4x4*

GENERAL APPEARANCE no acute distress, pleasant, alert, Well-developed and appears non-toxic.  HEENT: HEAD: normocephalic/atraumatic, EARS: external canals clear, tympanic membranes pearly bilaterally, EYES: no conjunctival erythema, no discharge, NOSE: nose clear, no nasal flaring, THROAT: dentition normal, tonsils not enlarged, pharynx and tonsils without erythema or exudates, post-nasal-drip.  NECK/THYROID: no lymphadenopathy.  CARDIOVASCULAR: regular rate and rhythm, normal S1S2, no murmurs, no gallops, no rubs.  RESPIRATORY: no use of accessory muscles, clear to auscultation bilaterally, no wheezes, no rhonchi, no rales.  GASTROINTESTINAL: soft, nontender, nondistended.  SKIN: no rash, no skin lesions.  


Could you explain what elements in the example that you would use that would qualify as detailed with the 4x4 tool.


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## Tonyj (Feb 8, 2013)

Cardiovascular and Respiratory, yes.  Throat, yes. Eyes and Ears I'm on the fence. I see your point, I'm leaning yes but... Good question for the webinar.


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## JDACPC (Feb 8, 2013)

You need 4 elements in 4 organ systems.  Eyes is one organ system, the note would have to mention 4 elements, like, pupils equal (1), round (2), reactive to light (3), and accomodation (4).  In this example you only have two elements for the eye system and eight-ten for the ears/nose/throat/mouth organ system.

I have never counted each eye but now that I think about it, if it mentions different findings on the left versus right, I'm thinking you could count each point.  Agreed, good question for the webinar.


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