Would the below be a detailed exam per 1995 guidelines? If going by this link http://www.ngsmedicare.com/ngs/wcm/c...eDefaultDesc=0
It says for detailed exam, "2 to 7 areas or systems (Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon)"
For the Eczema below I got neck, head and chest, that's 3 body areas, and it mentions there's itchy, erthematous papules, not just a check off list. Is that sufficient to be qualified as detailed exam? Help appreciated.
Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
- Patient is a 28 year old female who appears to be well developed and well nourished with good attention
to hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
- Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
- Above the Waist exam was performed on scalp (including hair), head (including face), neck, axilla, right
upper extremity, left upper extremity, hands, chest, abdomen, back, and breast.
Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek
Medical Decision Making: Eczema , problem worse, dermatitis skin care demonstrated in the office,
reviewed verbally, and handout given to patient
POC: Rx Triamcinolone 0.1% topical cream [triamcinolone 0.1% topical cream] apply BID on affected
areas , cetirizine 10 mg oral tablet [cetirizine 10 mg oral tablet] PO QD in AM , Elidel 1% topical cream
[pimecrolimus 1% topical cream] use twice daily
Recommendation is Explained medication should not be applied on the face unless directed., Explained
topical medication is for itching as needed. Patient should continue to keep skin well moisturized even
when asymptomatic., tested out protopic gel and elidel cream on split face for 10 mins. duing office visit.
along with vanicream moisturizer on face. pt likes the combination of elidel cream and vanicream better.
2. Xerosis
Dry located on face, left upper extremity and right upper extremity
Medical Decision Making: Xerosis , observe
POC: Recommendation is Can use a lighter lotion in the morning before getting dressed and a thicker
one such as vaseline in the evening after bath/shower., Develop habit of applying moisturizer at least
twice daily. Recommend unscented products such Vanicream., Dry skin instruction / handout given
It says for detailed exam, "2 to 7 areas or systems (Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon)"
For the Eczema below I got neck, head and chest, that's 3 body areas, and it mentions there's itchy, erthematous papules, not just a check off list. Is that sufficient to be qualified as detailed exam? Help appreciated.
Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
- Patient is a 28 year old female who appears to be well developed and well nourished with good attention
to hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
- Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
- Above the Waist exam was performed on scalp (including hair), head (including face), neck, axilla, right
upper extremity, left upper extremity, hands, chest, abdomen, back, and breast.
Exam:
1. Eczema
Erythematous papules, itching located on anterior neck, breast, forehead, left cheek and right cheek
Medical Decision Making: Eczema , problem worse, dermatitis skin care demonstrated in the office,
reviewed verbally, and handout given to patient
POC: Rx Triamcinolone 0.1% topical cream [triamcinolone 0.1% topical cream] apply BID on affected
areas , cetirizine 10 mg oral tablet [cetirizine 10 mg oral tablet] PO QD in AM , Elidel 1% topical cream
[pimecrolimus 1% topical cream] use twice daily
Recommendation is Explained medication should not be applied on the face unless directed., Explained
topical medication is for itching as needed. Patient should continue to keep skin well moisturized even
when asymptomatic., tested out protopic gel and elidel cream on split face for 10 mins. duing office visit.
along with vanicream moisturizer on face. pt likes the combination of elidel cream and vanicream better.
2. Xerosis
Dry located on face, left upper extremity and right upper extremity
Medical Decision Making: Xerosis , observe
POC: Recommendation is Can use a lighter lotion in the morning before getting dressed and a thicker
one such as vaseline in the evening after bath/shower., Develop habit of applying moisturizer at least
twice daily. Recommend unscented products such Vanicream., Dry skin instruction / handout given