Wiki Exam documentation - Conjunctivae/Lids: within normal limits

[AR2728]

We have a new dermatologist to our office, following is how she is documenting her exam:

General Appearance: well-developed, well nourished, no apparent distress
Mood/Affect: cooperative
Orientation: alert and oriented x 3
Scalp/Hair: within normal limits
Head/Face: macule on left mandible
Conjunctivae/Lids: within normal limits
Lips/Teeth/Gums: within normal limits
Oral Mucosa/Tongue: within normal limits
Neck/Thyroid: within normal limits
Right Upper Extremity: within normal limits
Left Upper Extremity: within normal limits
Nails/Digits: within normal limits

So, I'm confused by her documentation. Would this be expanded based on 95 and 97 guidelines? Any advice would be much appreciated! For the 97 I was giving a point for RUE and a point for LUE, but unsure if this is accurate.

 

[sofcampbell]

Derm exam

I actually would say it is a detailed exam. Per 97guidelines you have 12 bullets, you are correct by giving 1 for each extremity that was examined. If you use 95 then it will depend on your interpretation of detailed vs. expended problem focused. Some carriers consider examination of 2-4 body areas/organ systems an EPF exam and 5-7 a detailed exam. Others consider 2-7 body areas/organ systems for both EPF and Detailed, so it becomes rather subjective how to interpret EPF vs. Detailed exam. Yet I'd still say it is a detailed exam.

Sofia Delmas, MS, CPC

 

[AR2728]

Thanks-That makes sense.