Wiki cardio exam level

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JLViolet

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This is for an Inpt cardiology consult, billing 99255. I am do not think this fits comprehensive level, but maybe I am wrong, or thinking about it too much? I question the musculo exam part? Looking for input before contacting doctor. Thanks.

General: No acute distress. (Note does have 3/7 vital signs tho)
Eye: Normal conjunctiva.
HENT: Normocephalic, Oral mucosa is moist.
Neck: No carotid bruit, No jugular venous distention.
Respiratory: Lungs are clear to auscultation, Respirations are non-labored.
Cardiovascular: S1 (Normal), S2 (Normal/Split), No murmur, No edema, Precordium quiet, no thrill or heave, No clicks present.
Arterial pulses: Upper extremity, Lower extremity, Within normal limits.
Gastrointestinal: Soft, No organomegaly.
Musculoskeletal: No swelling.
Integumentary: Warm, Pink.
Integumentary exam: Not cyanotic.
 
JLViolet said:
This is for an Inpt cardiology consult, billing 99255. I am do not think this fits comprehensive level, but maybe I am wrong, or thinking about it too much? I question the musculo exam part? Looking for input before contacting doctor. Thanks.

General: No acute distress. (Note does have 3/7 vital signs tho)
Eye: Normal conjunctiva.
HENT: Normocephalic, Oral mucosa is moist.
Neck: No carotid bruit, No jugular venous distention.
Respiratory: Lungs are clear to auscultation, Respirations are non-labored.
Cardiovascular: S1 (Normal), S2 (Normal/Split), No murmur, No edema, Precordium quiet, no thrill or heave, No clicks present.
Arterial pulses: Upper extremity, Lower extremity, Within normal limits.
Gastrointestinal: Soft, No organomegaly.
Musculoskeletal: No swelling.
Integumentary: Warm, Pink.
Integumentary exam: Not cyanotic.
Click to expand...

I don't think I would consider this Comprehensive under '95 DG...the muskulo isn't specific enough, IMO, to warrant credit. I'm coming up 6 with Organ systems: Eye, ENT, Resp, Cardio, GI, Integ, for a Detailed Exam.
 
mhstrauss said:
I don't think I would consider this Comprehensive under '95 DG...the muskulo isn't specific enough, IMO, to warrant credit. I'm coming up 6 with Organ systems: Eye, ENT, Resp, Cardio, GI, Integ, for a Detailed Exam.
Click to expand...

I agree that it does not meet comprehensive - however if the doctor did document the vitals, then I would add Constitutional, making it 7 systems. If he had said joint swelling instead of just swelling, then he would have comprehensive!
 
Thank you all for the input. I was having difficult time seeing it as comprehensive as well.
 
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