Wiki 1995 guidelines

[drsunitha]

Hi,

how far is it true that while using 1995 guidelines ,just writing normal for examination is ok

eg:- respiratory system - normal
or
respirtory system -lungs clear,vesicular breathing

dia - tonsillitis

res -normal
ent -throat congested
gi -normal
skin -normal
haem-normal

mdm -moderate

physician want me to give 99214 .i think this examination is not sufficient.

your valuable advices are welcome.

sunitha

 

[MnTwins29]

At best, an EPF exam

I wouldn't use a detailed exam for this as there wasn't much done on each system - since these are brief descriptions, I believe the best you can do is EPF given this documentation.

However, 99214 may not be completely ruled out, as if there is detailed or comprehensive history and MDM of moderate or high level, that would meet the 2 of 3 requirement for an established patient.

 

[mdoyle53]

for a detailed exam using 95 guidelines, you need to have one system that is examined in more detail. I do not see any system that is examined in more detail so the exam part of the visit would not qualify as detailed.